RC 


UC-NRLF 


B  ^  bai  57b 

TRANSACTIONS 


OF  THE 


Chicago  Urological  Society 


For  the  Year  1915-1916 


Reprinted  From 


CHICAGO 
1916 


Jj$i 


TRANSACTIONS 


OF  THE 


Chicago  Urological  Society 


For  the  Year    1915-1916 


President: 

HERMAN  L.  KRETSCHMER. 

Vice-President: 

D.  R.  McMARTIN. 

Secretary: 

IRVIN  S.  KOLL. 


CHICAGO 
19  16 


INDEX. 


PAGE 
Adeno-Carcinoma   of   the   Kidney,   Primary.      Illustrated.      By  J.   S.    Eisen- 

staedt,    M.    D 18 

American  Uroicgica!  Association  (North  Central  Section)  with  the  Chicago 
Urological  Society,  Transactions  of.  Meeting  November  12th  and 
13th,    1915     90 

Aspermatism.      By  V.   D.   Lespinasse,   M.   D 213 

Chicago    Gynecological    and    Chicago    Urological    Societies,    Joint    Meeting, 

Transactions    of,    March    17th,     1916 170 

Chicago    Medical    and    Urological    Societies,    Joint    Meeting,    Transactions 

of,    January    5th,    1916 143 

Chicago  Urological  Society,  Transactions  of.  Meeting  October  21st,  1915..  54 
Chicago  Urological  Society,  Transactions  of.  Meeting  April  i3th,  1916....  197 
Chicago  Urological  Society,  Transactions  of.  Meeting  May  25th,  1916.  .  .  .  214 
Cystinuria    and    Cystin    Stones,     With    a    Report    of    a    New    Family    of 

Cystinurics.      Illustrated.      By   Herman  L.   Kretschmer,    M.   D I 

Cystoscopic  Burn,  A  Very  Unusual  Case  History  Presenting  Among  Other 

Features  a.      Ilustrated.      By   F.   R.  Charlton,   M.   D 31 

Epididymitis     (Acute),     Surgical     Treatment     of.       By     Charles     M.     Mc- 

Kenna,    M.    D 192 

Gonorrhea  and  Marriage.     By   Irvin  S.  Koll,  M.  D 141 

Gonorrhea     in     the     Male     (Acute),     Complications     of.       By     Robert     H. 

Herbst.    M.    D 1 30 

Gonorrhea  Complement  Fixation  Test.      By  V.  D.   Lespinasse,   M.  D 128 

Immunity,   The    Bio-Chemistry   of    the   Gonococcus    in    Its   Relation    to.      By 

Carl   C.   Warden,    M.    D 125 

Infections,    Some    Factors    in    the    Diagnosis    of    Kidney    and    Bladder.      By 

Arthur   H.   Curtis,   M.   D 162 

Infection   of    the    Kidneys    and    Ureters,    Clinical    Review    of   240    Cases   of 

Non-Surgical.      By  Gilbert  J.  Thomas,   M.   D 66 

Inflammation    of    the    Seminal    Duct,    Treatment    of    Non-Tuberculous.      By 

R.   W.   Staley,   M.   D 73 

Operations   by    Local   Anesthesia    on    the    External    Genitalia    and    Prostate. 

By  A.  C.  Stokes,  M.  D 49 

Operative    Urethroscope,    A    New    Form    of.       Illustrated.       By    Ernest    G. 

Mark,    M.    D  .  . 37 

Phylacogen  in  Urological   Practice.      By   Frederick   W.   Robbins,   M.   D...      56 

Prostitution    and    Gonorrhea.      By    Lewis    W.    Bremerman,    M.    D 138 

Pyelitis,  Treatment  of.     By  Herman  L.  Kretschmer,  M.  D 166 

Pyelo-Cystitis    in    Infancy,    Course    and    Prognosis    of.       By    Clifford    G. 

Grulee,    M.    D 1 58 

Pyelitis    in    Pregnancy,   Some   Observations   on.      By   J.    Clarence   Webster, 

M.  D 151. 

Renal    Pelvis,    Some    Studies   on    the    Anatomy   of.      By    Daniel    N.    Eisen- 

drath,  M.  D 188 

Radiotherapy    and   Diathermy   in    Malignant   Tumors   of    the    Bladder.      By 

G.   Kolischer,   M.   D 26 

iii 


713224 


PAGE 

Seminal   Vesiculilis.      By   Edward   W.   White.    M.    D 205 

Seminal    Vesicles,    Anatomy    and    Pathology    of.       Illustrated.      By    E.    O. 

Smith,    M.    D 40 

Syphilis  of  the  Prostate.      By  A.  Ravogli,  M.  D 62 

Tabes,   The   Bladder   in   Early.      Report   of    a   Case.      By    Wm.   S.    Ehrich, 

M.  D 35 

Tuberculosis  of   the  Seminal  Vesicle  and  Epididymis.      By   H.   W.   Plagge- 

meyer,   M.   D 79 

Ureteritis,  Notes  on.     By  Harry  Kraus,  M.  D 195 

Vesical   Neck,  Chronic  Edema  of  the.     By   Henry  J.  Scherck,   M.  D 28 

Vulvo- Vaginitis  in  Children.     By   Isaac  A.  Abt,  M.   D 134 


CYSTINURIA    AND    CYSTIN    STONES. 

WITH    A    REPORT    OF    A    NEW 

FAMILY  OF  CYSTINURICS.* 

By  Herman  L.  Kretschmer,  M.  D.,  Chicago,  111., 

Urologist  to  Presbyterian  Hospital;  Junior  Surgeon  to  Chil- 
dren's   Hospital;    Ceniio-Urinar^    Surgeon    to 
Alexian    Brothers    Hospital. 

The  credit  for  having  first  described  cystin  as 
a  constituent  of  urinary  calcuH  is  given  to  Wollas- 
ton,  who  reported  his  discovery  of  a  new  constituent 
of  urinary  stone  in  The  Philosophical  Tremsactions 
of  London  for  1810.  Wollaston's  first  case  oc- 
cured  in  a  child  aged  5,  and  the  second  in  a  man 
of  46. 

The  term  cystic  oxide  was  used  by  Wollaston  in 
his  publication;  it  was  also  used  by  subsequent 
writers  on  this  subject,  namely,  by  Bennett,  Brande, 
Heath,  Jones,  Neill,  Schweig,  Stromeyer,  Thomp- 
son and  others.  Later,  this  term  was  changed  by 
Berzelius,  "because  the  substance  was  found  not 
to  be  an  oxide  (Fowler)." 

Frequency. 

Cystin  stones  belong  to  the  rarer  forms  of  urin- 
ary calculi.  Doubtless  because  of  their  rare  oc- 
currence, but  little  space  is  devoted  to  them  in  the 
various  text-books  on  urinary  surgery.  Since  the 
original  publication  of  Wollaston,  one  hundred  and 
fifteen  years  ago,  I  have  found  reports  of  107  cases 
of  cystin  stone,  including  the  two  cases  to  be  re- 
ported in  this  paper. 

It  has  been  my  good  fortune  to  see  two  cases 
of  this  rare  condition  within  a  year;  these  cases 
seem  worthy  of  report  for  the  following  reasons : 

1 .  The  two  cases  were  twin  boys,  aged  9. 

2.  Chemical  examinations  demonstrated  the 
fact  that  in  each  case  we  were  dealing  with  pure 
cystin  stones.** 

3.  A  positive  diagnosis  of  vesical  calculus  was 
made  in  each  case  before  operation  b^  C^stoscopic 
examination  and  X-ra^s. 

4.  In  both  cases  the  calculi  were  removed  by 
litholapaxy. 

5.  Other  members  of  the  family  show  the  pres- 
ence of  cystmuria. 

Case  1. — F.  D.,  male,  aged  9,  was  first  admitted  to  the 
Children's  Memorial  Hospital  to  the  service  of  Drs. 
Churchill    and   Walker. 

Present  Illness.  About  three  years  ago  the  patient  began 
to  suffer  from  constipation;  at  times  he  would  not  have  a 
bowel  movement  for  several  days  to  a  week.  Enemas  and 
medicine  were  used  regularly.  Soon  afterward  he  began 
to    have    great    difficulty    in    urination;    he    was    obliged    to 


*Read  at  the  meeting  of  the  Chicago  Urological  Society 
October  28,    1915. 

**I  am  indebted  to  Dr.  S.  A.  Amberg,  of  Sprague 
Memorial    Institute,    for    these   chemical    examinations. 


[Reprinted    from    THE    UROLOGIC    AND   CUTANE- 
OUS  REVIEW,   January,    1916.] 


strain  during  micturition,  and  on  exposure  to  cold  or 
wet  would  have  incontinence.  For  the  past  two  months 
he  urinated  very  frequently  and  involuntarily,  and  wet 
the  bed  regularly  every  night.  He  was  very  active,  had 
a   good   appetite  and  slept   well. 

Physical  Examination.  The  patient  is  a  well-developed 
boy,  bright  and  very  active.  The  skin  is  clear;  no  erup- 
tions. The  head  is  large  but  regular;  the  scalp  is  nega- 
tive. The  eyes  are  negative.  The  ears  are  negative  to 
external  examination,  as  is  also  the  nose.  The  mouth  and 
tongue  are  clean,  with  normal  membrane.  A  throat  cul- 
ture IS  negative  to  the  Klebs-Loeffler  bacillus.  There  are 
no  Koplik  spots  and  the  throat  is  negative.  The  teeth 
are  poor.  The  submaxillary  glands  of  the  neck  are  en- 
larged. The  lungs  are  negative.  The  heart  shows  a 
slight  irregularity  but  there  is  no  enlargement.  The  ab- 
domen is  held  somewhat  tense.  The  liver  and  spleen  are 
not  palpable.  The  penis  is  well  developed.  Urine 
dribbles  continually.  The  extremities  are  negative.  All 
reflexes    are    normal. 

Second  Admission.  August  4,  1914,  the  child  was  read- 
mitted to  the  hospital  for  the  same  trouble,  incontinence  of 
urine.  The  incontinence  seemed  to  be  a  great  deal  worse 
while  the  child  was  in  school.  He  has  had  no  pain  on 
urination  nor  any  difficulty  in  starting  the  stream.  August 
13,  1914,  the  patient  had  acute  retention  and  was 
catheterized,  4  ounces  of  urine  being  removed.  August  28, 
about  10  a.  m.,  the  patient  complained  of  abdominal 
pain,  but  said  nothmg  further  about  this,  playing  around 
as  usual.  At  4  p.  m.  he  went  to  bed,  complaining  of 
chilliness.  His  temperature  at  5:45  was  103J/2.°  He  re- 
fused supper.  At  6  p.  m.  the  patient's  face  was  flushed; 
he  was  feeling  hot  and  he  said  his  'head  hurt.'  The 
physician's  examination  revealed  nothing  abnormal  in  the 
lungs.  There  was  a  faint  systolic  whiff  at  the  apex,  but 
it  was  not  transmitted  elsewhere.  The  throat  was  red- 
dened and  the  tonsils  were  slightly  prominent.  The  ab- 
domen showed  voluntary  spasm,  but  there  was  no  tender- 
ness. Tympanites  everywhere  except  over  the  bladder. 
The  liver  was  palpable,  but  the  spleen  and  kidneys  were 
not.  No  costovertebral  tenderness.  The  patient  was 
catheterized,   but   urine   showed  no   abnormal  features. 

X-ray  examination  revealed  three  irregularly  oval-shaped 
bodies,  possibly  stones,  at  the  base  of  the  bladder.     (Fig.  I.) 

Cystoscopic  examination.  Twelve  ounces  of  urine  were 
withdrawn  by  catheter.  There  was  no  cystitis.  The  right 
ureteral  orifice  appeared  a  little  larger  than  the  left. 
Three  stones  were  seen  in  the  base  of  the  bladder,  about 
the  size  of  a  small  hazelnut,  whitish  in  color,  with  irregu- 
lar surface. 

Urinalysis.  The  urine  is  very  pale,  clear  and  alkaline. 
There  is  no  sugar.  Albumin  is  present.  There  is  no  sedi- 
ment, no  casts,  but  a  considerable  number  of  squamous 
epithelial  cells  and  many  pus  cells. 

Operation.  September  14,  1914,  I  carried  out  litho- 
tripsy under  ether  anesthesia.  About  a  leaspoonful  of  de- 
bris was  removed  by  the  use  of  the  evacualor.  Revisionary 
cystoscopy  failed  to  show  any  fragments.  There  was 
some  redness  of   the  bladder  and  a   few  areas  of  edema. 

Case  2.  R.  D.,  male,  aged  9,  was  admitted  to  the 
Children's  Memorial  Hospital  to  the  service  of  Drs. 
Churchill  and  Ryerson.  His  first  admission  was  for  an 
operation  for  paralysis  of  the  left  upper  arm  muscles,  fol- 
lowing anterior  poliomyelitis.  He  was  readmitted  February 
20,  1915.  Since  leaving  the  hospital  he  has  been  well 
except  for  his  urinary  distress,  which  consisted  of  pain  in 
the  suprapubic  region,  pain  in  the  urethra  during  urina- 
tion, and  the  passage  of  sand.  There  has  also  been  some 
dribbling  of  urine  for  the  past  eight  days.  The  pain  in 
the  suprapubic  region  he  attributed  to  an  injury  received 
six   or   eigh   months   ago. 

History  (patient's).  About  a  week  after  leaving  the 
hospital  in  July,  1913,  he  began  to  have  pains  on  urination 
and  excepting  for  two  days  shortly  after  the  beginning  he 
has  had  pain  ever  since.  He  attended  school  up  to  two 
weeks  before  coming  to  the  hospital.     Urine  has  been  passed 


r 


Jifr'    nj-i 


Fig.  I. 

Showing   presence    of    3    calculi    in    the    bladder.      Upon    examination  they  proved  to  be  pure  cyslin  stones. 


Fig.  11. 


Shows    presence    of    a    very    large    stone    which    upon    examination    after 
litholapaxy    revealed    the    presence    of    pure    cystin. 


with  difficulty,  coming  slowly,  and  has  contained  white 
stringy    masses. 

Physical  Examination.  The  boy  is  small  and  only 
fairly  well  developed.  He  cries  a  great  deal  with  pain 
in  the  region  of  the  bladder.  The  head  is  normal.  The 
chest  is  bony  and  poorly  nourished,  though  the  resonance, 
heart  borders,  respiratory  murmurs  and  heart  sounds  are 
normal.  The  muscles  of  the  abdomen  are  tense ;  palpation 
over  the  lower  border  elicits  pain.  There  is  an  area  of 
dulness  about  the  breadth  of  two  fingers  above  the  pubes. 
The  rectal  examination  is  negative.  The  liver  and  spleen 
are  negative.  The  left  arm  is  much  smaller  than  the 
right.  The  left  is  partly  paralyzed.  On  its  anterior 
aspect  at  the  shoulder  is  a  scar  where  an  operation  for 
tendon  transplantation  has  been  done.  The  patellar  re- 
flexes were  not  obtainable.  The  penis  is  in  semi-erection 
almost    continually,    and    urine    dribbles    away    involuntarily. 

Blood  Examination.  Hemoglobin,  70  per  cent.;  red 
blood  cells,  4,460,000;  white  blood  cells,  14.700;  poly- 
morphonuclears, 56  per  cent.;  small  morphonuclears,  44  per 
cent. 

Urinalysis.  The  urine  was  clear,  and  contained  acid, 
albumin  and  sugar.  A  culture  revealed  the  Bacillis  coli 
communis. 

Cystoscopy.  Examination  with  the  cystoscope  showed 
the  presence  of  a  large  stone  in   the  bladder. 

X-Ray  Examination.  The  x-ray  showed  one  stone  in 
the  bladder    (Fig.  2). 

Operation.  March  2,  1915,  at  8  a.  m.,  litholapaxy  was 
performed  under  ether  anesthesia  and  more  than  two  table- 
spoonfuls  of  debris  removed.  Subsequent  cystoscopic  ex- 
amination  showed   the   bladder   free    from   stone   or   detritus. 

Because  of  the  well  known  fact  that  cystinuria 
occurs  in  families,  it  was  thought  desirable  to  ex- 
amine the  urine  of  the  other  members  of  the  family. 
The  father's  urine  could  not  be  obtained.  The 
mother's  urine  was  negative.  The  urine  of  the  two 
sisters  showed  cystin  crystals.  The  urine  of  the 
remaining  boy  showed  the  presence  of  a  sulphur 
reaction,  but  no  crystals  were  demonstrated  in  his 
urine.  So  that  of  the  six  members  of  this  family 
(excluding  the  father,  who  would  not  send  in  a 
specimen  of  urine),  two  had  cystin  stones,  two 
showed  the  presence  of  cystin  crystals,  one  showed 
the  presence  of  a  sulphur  reaction,  and  the  sixth 
was  normal. 

Analysis  of  the  Cases  Reported  in 
Literature. 

Because  of  the  rare  occurrence  of  cystin  stone 
it  was  thought  desirable  to  review  the  cases  re- 
ported in  the  literature  and  to  present  the  results 
in  brief  form. 

It  was  at  once  apparent  that  in  a  very  large  num- 
ber of  cases  reported  (  1  06)  ,  very  meagre  descrip- 
tions were  given,  and  in  some,  many  of  the  more 
or  less  important  details  were  omitted,  so  that  the 
total  number  of  accurately  reported  cases  is  far  be- 
low the  total  number  of  cases  reported. 

If  we  consider  the  frequency  of  urinary  stone, 
and  the  large  numbers  of  cases  reported,  this  series 
of  I  06  cases  is  a  very  small  percentage  of  the  total, 
so  that  we  may  freely  say  that  cystin  calculi  are 
indeed  very  rare. 

Sex. — There  were  sixty-five  males  and  twenty- 
seven  females;  in  fourteen  cases  nothing  was  stated 


regarding  the  sex  of  the  patient.  It  is  quite  evi- 
dent that  cystin  stones  occur  much  more  frequently 
in  males  than  in  females.  According  to  these  fig- 
ures, 70.6  per  cent,  of  the  cases  occurred  in  males. 
Age. — In  thirty-two  cases  the  age  was  not  stated. 
In  the  remaining  cases  in  which  the  age  was  stated, 
the  following  figures  were  obtained : 

I  to  1  0  years 15  cases 

II  to  20  years 9  cases 

21  to  30  years 19  cases 

31  to  40  years 15  cases 

41  to  50  years 9  cases 

51  to  60  years 4  cases 

61  to  70  years 0  cases 

71  to  80  years 1  case 

The  youngest  case  was  reported  by  Manby, 
whose  patient  had  passed  a  small  waxy-looking 
cystin  stone  when  only  twelve  months  old.  The 
oldest  patient  was  reported  by  Henry  Thompson. 
His  patient  was  8 1  years  old  and  was  reported  well 
at  84. 

In  73.34  per  cent,  of  the  cases,  the  stones  oc- 
curred before  the  age  of  40.  There  were  only 
seven  cases  reported  above  50.  In  only  one  case 
do  we  find  cystin  stone  associated  with  prostatic 
hypertrophy,  namely,  in  Fowler's  case  in  which  a 
perineal  prostatectomy  was  performed. 

From  this  evidence  it  is  quite  apparent  that  cys- 
tin stone  is  a  disease  of  the  young,  and  that  as  an 
accompaniment  of  prostatic  disease  in  the  aged, 
where  we  frequently  find  associated  stone,  it  is  of 
great  rarity. 

Location  of  Cystin  Stones. 

In  thirty-four  cases  no  statements  were  made  rela- 
tive to  the  location  of  the  calculi.  In  thirty-seven 
the  patients  passed  one  or  more  calculi  per  urethra. 

An  interesting  case  is  reported  by  Neill,  in  which 
the  calculi  were  discharged  through  a  suppurating 
wound  in  the  abdominal  wall.  The  patient  evi- 
dently had  a  perirenal  abscess  that  ruptured  an- 
teriorly. During  the  course  of  several  months  thir- 
teen calculi  were  discharged  through  the  wound. 

In  one  case  the  stone  lodged  in  the  urethra  (Win- 
ternitz) . 

The  bladder  was  the  seat  of  one  or  more  calculi 
in  forty-one  cases,  and  the  kidneys  in  seventeen.  In 
two  of  the  kidney  cases  the  stones  were  bilateral. 
These  are  reported  by  Bennett  and  Link.  In  two 
cases  (Mu'ller,  Link)  stones  were  found  in  the  blad- 
der and  kidneys.  Link's  case  had  several  calculi 
in  the  right  kdiney  and  one  large  one  in  the  bladder. 

Number  of  Stones. 

Cystin  calculi  may  be  single  or  multiple.  The 
largest  number  of  cystin  stones  to  be  obtained  from 
one  patient  was  forty-five,  reported  by  Rosenstein. 
Lichtenstern  removed  twenty-nine  from  the  kidney 
of  a  patient,  and  Neill  reported  thirteen  stones  from 

6 


his  patient.  In  thirty-nine  cases  the  presence  of  one 
stone  was  recorded.  Multiple  stones  were  reported 
in  thirty-eight  Ccises. 

Method  of  Obtaining  Stones. 

In  two  cases  the  stones  were  obtained  at  autopsy 
(Bennett,  Bence-Jones). 

Lithotrity  was  carried  out  by  Chabrie,  Wasser- 
thal,  MacPhail,  Miiller,  Sautham,  Thompson, 
Thorndike  and  Ogren,  and  Kretschmer. 

In  the  two  cases  reported  in  this  paper  I  had  no 
difficulty  in  crushing  the  stones.  That  they  are 
susceptible  of  being  crushed  is  further  proven  by 
reports  of  other  authors.  I  therefore  cannot  agree 
with  the  statement  that  these  calculi  cannot  be 
crushed. 

The  largest  cystin  stone  was  removed  by  Reginald 
Harrison  by  lateral  lithotomy.  The  stone  weighed 
1050  grains  and  was  exhibited  because  of  its  size, 
which  was  the  largest  on  record. 

Occurrence  of  Cystinuria  in  Families. 

One  of  the  peculiar  characteristics  of  cystinuria 
is  its  tendency  to  occur  in  families,  a  trait  that  has 
been  recognized  for  a  long  time.  This  well-known 
clinical  fact  should  always  be  borne  in  mind  when- 
ever the  diagnosis  of  cystinuria  or  cystin  stone  is 
made,  so  that  we  may  be  on  our  guard,  and  examine 
carefully  the  urines  of  the  other  members  of  the  fam- 
ily. In  the  two  cases  reported  in  this  paper,  we 
were  fortunate  to  obtain  urines  from  all  of  the  rest 
of  the  family  except  the  father,  the  results  of  which 
are  mentioned  above. 

One  of  the  most  carefully  studied  and  oft-quoted 
of  these  cystin  families  is  the  one  reported  by  Ab- 
derhalden:  "Kaufman  in  the  autopsy  of  a  2I|/2 
months  old  child  that  had  died  of  inanition  found 
all  the  organs  infiltrated  with  numberless  white 
points.  A  section  of  the  spleen  given  to  Abderhal- 
den  for  examination  showed  that  the  deposits  were 
cystin.  Two  other  children  of  the  family  died  in  the 
same  way,  a  girl  of  9 1/2  months  and  a  boy  of  1  7 
months.  Two  boys  are  still  living  and  have  cys- 
tinuria. The  father's  urine  contains  cystin,  the  mo- 
ther's does  not." 

J.  Cohn  reported  a  family  of  cystinurics  in  1  899. 
The  family  consisted  of  twelve  members.  Two  of 
these  could  not  be  examined.  Of  the  remaining  ten 
members,  cystin  was  found  in  the  urine  of  seven, 
the  mother  and  six  children.  According  to  Cohn, 
this  is  the  largest  number  reported  in  any  one  family. 
Two  twins  aged  1 0,  had  enormous  amounts  of 
cystin  in  the  urine. 

Strasser  in  a  discussion  of  Brik's  paper  reported 
a  family  in  which  cystinuria  and  cystin  stones  were 
observed  in  almost  all  of  the  members  in  three  gen- 
erations. 

A.  Miiller  quotes  Teall  who  saw  it  in  five  mem- 
bers of  the  same  family;  and  Toel  who  reported 
the  disease  in  a  mother  and  two  daughters. 


E.  Pfeiffer  has  reported  four  cases  which  occur- 
red in  two  sisters  and  two  brothers.  The  two  chil- 
dren of  the  oldest  sister  have  no  cystin  in  their 
urines. 

Lichtenstern  reports  two  brothers,  both  suffering 
from  cystin  calculi. 

Harnier  has  also  reported  the  cases  of  two 
brothers,  both  suffering  from  cystinuria  that  some- 
times increased  to  such  an  extent  that  gravel  or 
small  stones  were  passed. 

A  case  of  cystin  calculus  from  a  cystin  family  is 
reported  by  Winternitz. 

The  number  of  cystin  families  no  doubt  could  be 
increased  if  care  were  exercised  in  studying  these 
cases.  In  many  of  the  reported  cases  the  state- 
ment is  made  that  other  members  of  the  family 
suffered  from  stone,  nothing,  however,  being  said  as 
to  the  nature  of  the  stones  or  the  condition  of  the 
urine.  There  can  be  little  doubt  that  a  certain 
number  of  these  cystin  families  have  been  over- 
looked in  this  way. 

Bearing  on  the  hereditary  phase  of  this  topic 
is  an  article  by  Southam.  He  reported  the  case 
of  an  unmarried  female  who  was  operated  on  for 
cystin  stone  in  the  kidney.  She  was  the  daughter 
of  a  woman  operated  on  by  Southam's  father  for 
cystin  stone  twenty-four  years  previously.  Eight 
years  after  the  mother  was  operated  on  her  urine 
still  showed  cystin.  The  patient  reported  still  has 
cystin  in  her  urine,  fourteen  years  after  operation. 

Occurrence  of  Cystin  Outside  of  the 
Urinary  Tract. 

A.  Occurrence  in  the  Blood.  Miiller,  as  far 
as  I  know,  has  been  the  only  one  to  report  the  oc- 
currence of  cystin  in  the  blood.  A  peculiar  point 
in  his  case  was  a.  "stubborn  urticaria  from  Decem- 
ber, 1902,  to  February,  1903."  During  this  time 
the  patient  had  moderate  attacks  of  colic  with  dis- 
charge of  small  cystin  concrements,  and  a  cystin 
crystal  was  also  found  in  the  blood.  This  was 
given  as  a  probable  cause  of  the  urticaria. 

B.  Occurrence  in  the  Internal  Organs.  That 
cystin  may  be  found  in  the  internal  organs  is  proven 
by  the  autopsy  findings  of  Abderhalden.  This, 
however,  is  a  rare  occurrence.  Sherer  found  cystin 
in  the  liver  of  a  drunkard  who  had  died  of  typhoid. 
In  Ultzman's  case,  the  liver  was  carefully  exam- 
ined after  death,  but  neither  cystin  nor  taurin  could 
be  demonstrated  in  the  liver,  spleen  or  kidneys. 
According  to  Garrod,  Kulz  obtained  it  on  one  oc- 
casion among  the  products  of  pancreatic  digestion 
in  vitro 

C.  Metastatic  Deposits  of  Cystin  in  Muscles  of 
Chest.  Umber  and  Burger  reported  an  unusually 
interesting  case  in  which  the  cystin  was  deposited 
in  the  right  pectoral  muscle.  The  patient  had  had 
a  left-sided  renal  colic,  associated  with  pus  and 
blood  in  the  urine.  There  was  gradual  disappear- 
ance of  the  blood  and  pus  and  of  the  kidney  pain, 

8 


followed  by  fever  and  a  hard  wood-like  infiltration 
of  the  right  pectoralis  region.  In  the  urine  were 
found  small  granules  of  cystin.  No  doubt  the  kid- 
ney colic  with  secondary  infection  was  due  to  ir- 
ritation by  cystin  concrements.  The  infiltration  in 
the  pectoralis  region  was  due  to  cystin  diathesis. 
The  body  tissues  were  supersaturated  with  the  cys- 
tin, which  is  only  slightly  soluble.  That  it  was  due 
to  the  cystinuria  is  shown  by  the  fact  that  when 
cystin  was  given  by  mouth,  and  when  the  meat  diet 
was  increased  with  consequent  increased  output  of 
cystin,  there  was  an  acute  exacerbation  in  the  in- 
filtration with  rise  of  temperature.  "On  June  21st, 
the  patient  was  discharged  well.  He  returned  on 
October  25th  and  a  subpectoral  abscess  was  opened. 
Eight  days  after  the  recurrence,  cystin  concrements 
reappeared  in  the  urine,  though  they  had  been  ab- 
sent for  months.  With  the  healing  of  the  abscess 
they  again  disappeared." 

D.  Occurrence  of  Cystin  in  Animal  Tissues. 
Cloetta  found  cystin  in  the  kidneys  of  an  ox  but 
failed  to  obtain  it  from  other  ox  kidneys  examined. 
Stromeyer  stated  that  Lassaigne  of  Paris  found  cys- 
tic oxide  in  a  stone  from  the  bladder  of  a  dog,  and 
Dreschsel,  according  to  Fowler,  found  it  in  the 
liver  of  a  horse. 

Varieties  of  Cystinuria. 

Temporary  cystinuria  has  been  reported  by  War- 
burg, whose  patient  had  a  hemorrhagic  cystitis. 
Tremsitory  cystinuria  has  been  reported  by  Simon 
and  Lewis,  associated  with  diaminuria. 

One  of  the  striking  chemical  characteristics  of 
these  stones  is  the  fact  that  when  found  they  are 
practically  always  pure  cystin,  with  the  exception 
of  MacPhail's  ( 1  )  case,  in  which  the  outer  surfacJe 
of  the  stone  was  cystin  and  the  interior  was  phos- 
phatic  with  a  mulberry  nucleus,  and  Ultzmcur's  (2) 
second  case,  in  which  the  nucleus  was  pure  cystin, 
the  rest  of  the  stone  consisting  of  earthy  phosphates 
and  calcium  oxalate. 

Duration  of  Cystinuria. 
With  the  passage  of,  or  the  surgical  removal  of, 
the  stones,  it  is  interesting  to  note  the  effect,  if  any, 
upon  the  cystinuria.  There  seems  to  be  no  hard 
and  fast  rule  about  it.  In  other  words,  removing 
the  stones  is  not  always  followed  by  a  disappearance 
of  the  cystinuria.  Thus  Roberts,  Schweig,  Heath, 
Ultzman,  Harrison,  Cohn  and  MacPhail  have 
recorded  a  disappearance  of  the  cystin  after  re- 
moval of  the  stones.  A  persistence  of  the  cystinuria 
after  removal  of  the  calculi  was  reported  by  Mor- 
eigne,  Staathogen  and  Briger,  Fowler,  Swarsen- 
sky,  Enwall  and  Southam.  In  one  of  Southam's 
cases  the  cystinuria  was  still  present  fourteen  years 
after  operation. 

Occurrence  of  Diamines. 
Various  diamines,  such  as  lysin,  putresin,  cada- 
verin,  leucin  and  tyrosin  have  been  reported  occur- 


ring  in  the  urines  of  patients  suffering  with  cystin- 
uria  or  cystin  stones. 

Origin  of  Cystin. 

A.  Synthesis  of  Cystin.  The  interest  in  the 
chemistry  of  cystin  was  greatly  stimulated  when 
Morner  showed  that  cystin  could  be  obtained  by 
the  hydrolysis  of  hair.  Two  years  later  Embden 
obtained  it  by  the  hydrolysis  of  serum  and  egg  al- 
bumin. Cystin  has  also  been  prepared  from  horn. 
This  has  been  described  by  Moorner. 

B.  Production  of  Cystin  in  the  Body.  Much 
remains  to  be  desired  in  our  knowledge  of  this  part 
of  the  question.  Many  theories  have  been  ad- 
vsmced  and  much  experimental  work  has  been  car- 
ried out,  but  no  definite  views  are  held  on  this  topic. 
The  modern  view  seems  to  be  that  it  is  due  to  some 
error  in  metabolism. 

According  to  Wells,  the  cystin  that  escapes  in 
the  urine  in  cystinuria  is  not  derived  from  intestinal 
putrefaction,  but  is  formed  in  the  tissues  from  the 
protein  molecule,  and  fails  to  be  further  decomposed 
because  of  some  anomaly  of  metabolism.  Wells 
further  states  that  the  metabolic  error  in  cystinuria 
is  not  complete,  for  only  a  portion  of  the  total  cystin 
of  the  catabolized  proteins  is  excreted  as  such  (Gar- 
rod). 

Moreigne  concludes  that  cystinuria  is  a  condi- 
tion due  to  retardation  of  nutrition,  caused  by  par- 
tial arrest  of  oxidation. 

Bodtker  does  not  accept  the  argument  of  Bau- 
man  and  Udransky  that  cystin  is  a  result  of  intes- 
tinal putrefaction,  but  concludes  that  it  is  an  inter- 
mediary product  of  albumin  metabolism  in  the  body. 
He  believes  that  the  diamines  are  also  intermediate 
{Jroducts  of  albumin  metabolism  that  are  further 
oxidized  in  the  normal  body,  but  in  the  cystinuric 
this  capacity  for  further  oxidization  is  lost. 

Abderhalden  and  Schittenhelm  believe  that 
cystinuria  is  probably  due  to  a  disturbance  of  in- 
termediate albumin  metabolism,  which  is  as  yet  so 
little  understood. 

Garrod,  who  has  made  an  extensive  study  of 
cystinuria,  and  after  quoting  various  theories,  says: 
"It  is  clear  from  all  this  that  we  are  still  far  from 
being  in  a  position  to  formulate  a  satisfactory  theory 
of  cystinuria.  Obviously  the  anomaly  is  a  very 
complex  one  of  different  range  in  different  cases  and 
even  of  distinct  natures." 

Garrod  furthermore  states  that  the  varying  ex- 
tent of  the  error  as  regards  the  number  of  protein 
fractions  involved  in  cases  of  cystinuria  suggests  that 
it  is  manifested  at  an  early  stage  of  the  catabolic 
series,  and  concerns  a  mechanism  which  deals  with 
a  number  of  amino  and  diamino  acids  in  common. 
Garrod  thinks  that  cystinuria  may  be  classed  as  an 
arrest  rather  than  as  a  perversion  of  metabolism. 

Ackerman  and  Kutscher  stated  that  it  is  gen- 
erally accepted  now  that  the  cause  of  cystinuria  is 
a  suppression  of  amino-acid  catabolism. 

10 


Wolf  and  Shaffer  give  a  detailed  report  of  meta- 
bolism experiments  in  two  cases  of  cystinuria,  with 
tables  showing  their  results.  With  reference  to  the 
origin  of  the  cystin  in  the  urine,  they  say  "The  cys- 
tin  in  high  protein  feeding  is  largely  of  exogenous 
origin,  but  a  part  is  probably  not  derived  from  food 
protein.  To  what  extent  strictly  endogenous  pro- 
cesses play  a  part  in  its  formation  it  is  impossible  to 
say," 

Alsberg  and  Folin  undertook  the  study  of  pro- 
tein metabolism  in  cystinuria.  The  patient  con- 
tinued to  eliminate  cystin  with  the  urine  at  the  end 
of  a  thirteen-day  feeding  experiment  with  a  diet 
containing  practically  no  protein  at  all.  They  fur- 
ther stated  that  if  the  daily  amount  of  cystin  elim- 
inated had  been  as  great  on  the  starch  as  on  the 
protein  diet,  it  would  have  been  clear  that  the 
origin  of  the  cystin  is  the  sulphur  coming  from  the 
body  tissues.  But  the  neutral  sulphur  values  show 
that  on  the  non-nitrogenous  diet  the  cystin  is  abso- 
lutely diminished,  and  relatively  to  the  total  sul- 
phur increase.  The  fact  that  the  neutral  sulphur 
remains  greater  than  normal  on  a  protein-free  diet 
and  relatively  more  prominent  than  on  a  protein- 
rich  diet,  taken  together  with  the  fact  that  the  pure 
cystin  does  not  pass  through  the  system  in  un- 
changed condition,  indicates  clearly  that  the  cystin 
which  is  eliminated  is -not  absorbed  as  such  from 
the  intestinal  tract.  The  facts  would  suggest  rather 
that  the  food  sulphur  which  is  eliminated  as  sul- 
phates may  be  absorbed  as  cystin  and  that  it  is  the 
sulphur  which  is  absorbed  in  large  or  different  com- 
plexes, together  with  the  sulphur  derived  directly 
from  the  tissues  which  the  cystinuric  individual  is 
unable  to  convert  normally  into  sulphates. 

They  conclude  that  in  view  of  the  inexplicable 
differences  between  their  results  and  those  of  Loewy 
and  Neuberg,  it  is  useless  to  dwell  on  explanations 
and  theories.     What  is  needed  is  more  facts. 

Thiele  reported  a  case  of  cystinuria  in  which  he 
investigated  the  effects  of  abstinence  of  food,  an 
almost  pure  carbohydrate  diet,  an  excessive  meat 
diet,  the  administration  of  tyrosin,  and  the  admin- 
istration of  some  of  the  patient's  own  purified  cys- 
tin. He  found  that  the  amount  of  cystin  excreted 
was  practically  independent  of  the  diet.  The  pa- 
tient was  able  to  break  up  cystin  administered  by 
the  mouth,  even  though  it  was  cystin  previously  ex- 
creted by  him,  his  tissues  having  been  unable  to 
break  it  up.  He  concludes  that  the  amido-acids 
are  not  absorbed  as  such,  but  are  denitrified  by  the 
intestinal  mucosa  and  converted  into  the  correspond- 
ing simple  fatty  acids  before  absorption.  In  cystin- 
uria a  defect  may  be  present  in  the  sulphur  remov- 
ing ferments,  the  denitrifying  ferments,  or  both.  The 
defect  appears  to  be  most  usual  in  the  tissues,  but 
may  also  occur  in  the  intestinal  mucosal  ferments. 

From  time  to  time  the  liver  has  been  supposedly 
the  organ  at  fault  in  cystinuria.  Marowski's  ob- 
servation on  the  association  of  cystinuria  with  acholia 

11 


has  been  adduced  as  evidence  pointing  toward  the 
hepatic  origin  of  cystin. 

Recent  work  by  von  Bergman  has  revived  the 
hepatic  origin,  or  at  least  resurrected  this  theory. 
He  has  shown  that  feeding  chohc  acid  to  dogs  in- 
creases the  amount  of  taurochohc  acid  in  the  bile 
for  a  time  until  the  reserve  supply  of  taurin-forming 
material  has  been  exhausted,  and  that  this  material 
may  be  replenished  by  the  administration  of  cystin, 
so  that  the  secretion  of  taurocholic  acid  begins 
anew.  On  the  other  hand,  feeding  cystin  alone 
does  not  increase  the  amount  of  taurocholic  acid. 
The  dog's  organism  has  evidently  a  reserve  supply 
of  taurin,  but  none  of  cholic  acid.  In  the  light  of 
this  work,  it  is  possible  that  cystinuria  is  a  functional 
disease  of  the  liver  in  which  too  little  cholic  acid 
is  formed,  so  that  but  little  sulphur  is  excreted  in 
the  bile  as  taurocholic  acid.  In  the  course  of  time 
this  might  lead  to  so  great  an  accumulation  of  the 
precursors  of  taurin  in  the  system  that  the  kidneys 
are  compelled  to  act  vicariously  for  the  liver  by 
excreting  cystin. 

Having  for  his  object  the  determination  of  the 
fate  of  cystin  in  the  body,  Blum  administered  cys- 
tin to  animals  in  different  ways,  mouth  and  intra- 
venously, in  an  attempt  to  find  out  how  it  was  dis- 
posed of.  He  found  that  only  small  amounts  could 
be  catabolized  when  given  intravenously,  but  that 
amounts  far  above  the  normal  could  be  disposed  of 
when  given  by  mouth.  A  flooding  of  the  intestine 
with  cystin,  even  to  the  limits  of  toxicity,  did  not 
cause  cystinuria.  This,  he  stated,  disposes  of  the 
theory  of  an  abnormal  catabolism  of  albumin  in  the 
intestine,  producing  so  much  cystin  that  it  cannot 
be  disposed  of  and  so  is  excreted  unchanged  in  the 
urine. 

Delepine  came  to  the  conclusion  that  the  deposi- 
tion of  cystin  crystals  was  favored  by  the  presence 
of  an  organism,  probably  one  of  the  blastomycites. 
His  work  has  not  received  confirmation. 

Because  of  the  presence  of  certain  diamines  in  the 
urine  and  feces  of  cystinurics,  Bauman  and  Udran- 
sky  suggested  a  hypothesis  in  which  they  set  forth 
views  that  cystinuria  was  due  to  intestinal  putre- 
faction. This  view  is  no  longer  held  by  modern 
workers  in  this  field. 

Diagnosis. 

Very  frequently  one  sees  the  statement  that  cys- 
tin stones  cannot  be  demonstrated  by  means  of  the 
Roentgen  ray.  Although  most  of  the  cases  were 
reported  prior  to  the  general  routine  employment 
of  X-rays  in  urinary  surgery,  in  those  of  more  re- 
cent date  in  which  the  X-rays  were  used,  one  finds 
positive  reports.  So  that  their  demonstration  with 
X-rays  is  quite  simple.  Link  (2  cases),  Rumpel, 
Berg,  Kretschmer  (2  cases),  Frankenthal  and  Lich- 
tenstern  have  all  reported  positive  X-ray  findings 
in  their  cases.  In  the  two  cases  reported  above  the 
diagnosis  was   made  once  by  the   Roentgen   rays 

12 


and  once  by  a  cystoscopic  examination,  which  was 
verified  by  a  subsequent  X-ray  examination. 

Treatment. 

The  treatment  of  cystin  calcuH  must  be  con- 
sidered under  two  headings: 

1 .  The  Calculi. 

2.  The  Cystinuria. 

The  appropriate  surgical  measure  to  be  insti- 
tuted depends  on  the  locality  of  the  stone.  When 
the  calculi  are  in  the  bladder,  litholapaxy  is  the 
operation  of  election.  That  it  can  be  carried  out 
is  demonstrated  not  only  by  the  two  cases  reported 
above,  but  by  the  reports  of  others.  Usually,  how- 
ever, the  calculi  are  small,  and  are  passed  spon- 
taneously by  the  patients.  This  was  recorded  in 
forty-one  cases. 

The  treatment  for  the  cystinuria  is  unsatisfactory. 
Many  of  the  cases  fail  to  respond  to  any  form  of 
treatment. 

DISCUSSION. 

Dr.  L.  W.  Bremerman:  I  should  like  to  ask  whether 
in  the  two  patients  operated  on  by  you  the  cystinuria 
persisted.  I  have  never  had  the  fortune  to  see  a  cystin 
stone.  I  understand  in  some  cases  the  removal  of  the 
stone  will  clear  up  the  cystinuria.  I  want  to  know  whether 
if  has  been   so  in   these  cases. 

Dr.  G.  Kolischer:  The  question  of  cystin  stones  or 
cystinuria  is  very  important  from  other  points  of  view 
than  those  mentioned  in  the  paper.  Cystin  stones  belong 
to  the  group  of  stones  that  are  used  as  an  argument  against 
the  old  Epstein  theory  that  it  is  necessary  for  the  forma- 
tion of  a  urinary  concretion  that  a  skeleton  must  be  pro- 
vided first,  and  on  this  the  deposit  of  urinary  salts  occurs, 
forming  the  calculus.  We  know  that  cystin  stones  are 
pure  cystin.  There  is  no  combination  with  any  other  ele- 
ments, so  that  we  consider  them  prototypes  of  all  primary 
stones;  not  due  to  inflammatory  processes;  not  due  to 
catarrhal  conditions  of  the  urinary  tract;  and  not  due  to 
bacterial  infection,  all  of  which  are  considered  as 
causes  for  deposits  anywhere  in  the  urinary  tract.  It  is 
very  interesting  from  this  standpoint  to  show  that  on  the 
Epstein  theory  cystin  is  a  product  of  the  incomplete 
metabolism  of  proteins.  Cystin  is  a  product  of  the  de- 
composition of  albumin  in  the  metabolism  of  the  body. 
Cystin  is  one  of  the  unfinished  body  products  of  the  in- 
complete metabolism  of  proteins,  and  consequently  a 
product  of  metabolism  and  not  a  product  of  the  genito- 
urinary tract  in  a  direct  sense.  The  proof  is  that  in 
poisoning  by  phosphorus  we  find  cystinuria.  As  long  as 
there  is  poisoning  cystinuria  is  maintained.  This  is  in- 
teresting on  account  of  the  influence  of  phosphorus  on 
the  liver  where  the  splitting  up  of  the  proteins  takes  place. 
It  is  a  product  of  metabolism,  for  occasionally  cystin  is 
found  in  all  the  organs  m  deposits  of  various  sizes.  The 
finding  of  sulphur  was  mentioned  by  Dr.  Kretschmer,  as 
also  that  cystinuria  runs  in  families.  Epstein  collected 
65  cases.  This  opens  up  the  possibility  of  rational  therapy 
to  prevent  these  concretions  on  the  same  plan  as  in  dia- 
betes, which  originally  was  considered  a  kidney  disease. 
As  to  therapy,  it  is  possible  to  do  a  lithotripsy.  In  former 
years  cystin  stones  were  not  removed  in  this  way  on  ac- 
count of  the  defective  instruments.  Nowadays  with  mod- 
ern instruments  we  can  crush  the  cystin  stones.  After  they 
are  caught  we  leave  them  in  the  grasp  of  the  forceps  for  a 
few  minutes  and  then  find  that  they  crush  easily.  Whether 
the  theory  of  Epstein  would  hold  in  other  cases  is  a  ques- 
tion for  discussion.  The  formation  of  a  concretion  in  the 
urinary  tract  does  not  depend  on  the  presence  of  an  or- 
ganic skeleton,  but  on  a  quick   change  in   the  concentration 

13 


of  the  urine.  For  instance,  a  flood  of  uric  acid  may  pro- 
duce a  quick  change  and  calcuh  may  follow.  Phosphatic 
and  uric  acid  concretions  are  explained  on  the  hypothesis 
that  the  skeleton  was  present  and  was  taken  in  with  the 
deposit  due   to  the  quick   concentration   of   the  urine. 

Dr.  D.  N.  Eisendrath:  Two  questions  interest  me: 
How  does  the  intensity  of  the  X-ray  picture  compare 
with  that  of  other  stones?  We  are  usually  taught  that 
cyslin  stones  give  the  lightest  shadow  of  any  of  the  calculi. 
What  is  your  personal  experience?  In  the  second  place, 
the  question  is  brought  up  as  to  a  matter  that  I  am  about 
getting  ready  to  take  hold  of  in  an  experimental  way, 
namely,  the  formation  of  calculi  and  their  reformation. 
There  was  an  article  by  Cabot  in  the  March  Surger}), 
Gynecology)  and  Obstetrics  on  the  reformation  of  calculi. 
I  called  attention  to  this  two  years  ago  in  a  paper  on  bi- 
lateral calculi,  in  which  I  reported  a  case  of  my  own 
and  one  of  Dr.  MacArthur's  cases.  In  both  cases,  in  spite 
of  the  fact  that  we  had  removed  the  calculi  in  two  separate 
operations  at  intervals  of  one  and  three  years,  the  calculi 
had  recurred.  It  brings  up  the  question  of  whether  it  is 
a  disturbance  of  metabolism,  or,  as  Dr.  Kolischer  has 
brought  out  in  the  theory  of  Kleinschmidt  and  Aschoff, 
concentration  of  the  urine  with  or  without  the  question  of 
infection.  Now  this  is  something  of  the  utmost  importance 
at  the  present  time  to  the  surgery  of  the  urinary  tract. 
It  has  got  to  be  such  an  important  thing  that  in  my  own 
cases  whenever  I  operate  on  a  patient  for  ureteral  or  renal 
calculus  I  cannot  assure  them  if  they  ask  me  the  ques- 
tion, "Is  the  stone  going  to  come  back?"  I  cannot  assure 
them  of  that  fact,  because  as  long  as  this  peculiar  tendency 
in  the  metabolism  of  the  patient  is  present,  as  it  was  present 
in  our  cases,  occurring  with  or  without  infection — being 
specially  favored  by  infection — we  are  never  sure  but 
what  they  will  recur.  We  had  recently  an  instance  of 
that.  Three  years  ago  I  look  a  small  stone  from  the 
parenchyma  of  a  kidney.  The  patient  came  back  again 
and  Dr.  Kolischer  saw  him.  The  X-ray  picture  showed 
a  very  faint  shadow  of  a  stone  filling  out,  apparently  the 
renal  pelvis.  A  year  or  two  later  another  picture  showed 
an  intense  shadow,  showing  how  the  stone  was  becoming 
more  and  more  dense.  This  whole  question  is  no  longer 
a  theoretical  one,  but  a  very  practical  one.  When  I  pre- 
sented this  case  of  bilateral  urinary  calculi  a  surgeon  sug- 
gested that  if  I  give  the  patient  nothing  but  distilled  water 
to  drink  he  would  never  have  a  recurrence.  We  know 
this  is  not  so.  It  is  some  factor  we  cannot  understand  at 
the  present  time.  We  see  it  in  cystitis,  in  the  phosphatic 
deposits  in  ammoniacal  cystitis,  how  these  deposit  them- 
selves on  the  walls  of  the  bladder  and  recur  and  recur 
until  we  get  rid  of  the  infection.  The  whole  question 
bi ought  up  by  cystmuria  of  the  tendency  to  recurrence  is 
one   of    great    interest    to   me. 

Dr.  H.  L.  Kretschmer:  In  reply  to  the  question  of  Dr. 
Bremeiman  as  to  whether  or  not  these  patients  still  have 
cystinuria,  it  was  my  intention  to  have  these  patients  send 
in  urines,  but  I  did  not  do  it.  When  the  paper  is  pub- 
lished I  shall  report  that  fact,  because  that  is  an  important 
fact  to  determine — whether  or  not  the  cystinuria  persisted 
long  in  these  two  cases.  Answering  Dr.  Eisendralh's  ques- 
tion about  the  X-ray  pictures,  I  wanted  to  bring  them 
along  but  forgot  them.  The  shadows  were  very  distinct — 
just  as  intense  and  easy  to  see  as  any  other  shadows.  The 
only  other  illustration  I  recall  was  one  by  Rumpel,  and  in 
this  case  it  was  distinct.  In  one  of  my  cases  the  urine  cul- 
ture was  sterile,  and  in  the  other  a  pure  culture  of  colon 
was  found.  I  agree  with  Dr.  Eisendrath  in  regard  to  the 
distilled  water.  I  have  seen  two  cases  of  recurrent  stone 
in  which  the  patients  drank  only  distilled  water.  In  both 
cases  stones  had  reformed,  so  that  I  do  not  think  distilled 
water  had  any  real  effect  on  preventing  a  recurrence  of 
the   stone    formation. 

Recent  examination  of  the  urines  show  that  the  cystinuria 
in  one  patient  has  completely  disappeared,  whereas  the 
other  patient  still   has  his   cystinuria. 

14 


BIBLIOGRAPHY. 

Abderhalden  and  Schittenheim.  Zeitschr.  f.  p/iVsio/ 
C/iem..    1905,  XIV.  468. 

Abderhalden  and  Schittenheim.  Zeibchr.  f.  ph\)siol 
Chem.,    1903,  xxxviii.   557. 

Ackermann.      Deutsch    me  J.    IVochenschr.,     1913,     xxxix, 

Ackermann,  D.  and  Kutscher,  F.  Zeilschr  f  Biol 
1911,  LVII,  355.  " 

Alsberg  and  Folin.  Amer.  Jour,  of  Physiology,  1905, 
XIV,  54.. 

Alsberg.  Carl  L.    Jour.  Med.  Research,  1904,  XIII,  105 

Barrels.      VirchoTv's  Arch.,    1863,  CXXVI,  419. 

Bary.  In  Beale,  Urine,  urinary  deposits  and  calculi. 
2nd  ed.,  Lond.,    1864,  page  354. 

Bennett.      Trans.  Path.  Sac.  of  Lond..   1850-52,  III,  383. 

Berg.  Verhandlungen.  d.  Deut.  f.  Urologie,  IV,  Con- 
gress,   1913. 

Bird.      Urinary  Deposits.      Philadelphia,    1863,   pp.    174- 

1 78. 

Biscons.      Toulouse   med.,    1909,  XI,  26-32. 

Blum.    Beilr.  z.  Chem.  Physiol,  u.  Path.     1903-04,  V    I 

Bley.      Buchner's   Reporter,    1835,   LVII,   p.  65. 

Bodtker.  (Beitrag.  zur  Kenntnis  der  c\istinurie. 
Zeitschr.  f.  physiol.   Chem.,    1905,   XIV,   393. 

Bowlby.  Trans.  Path.  Soc.  of  Lond.,  1888-1889,  XL, 
182. 

Buchner.     Buchner's  Reporter,    1825,  XXI,    113. 

Brande.  Quart.  Jour,  of  Science,  Literature,  Arts,  Lond., 
1820,  VIII,  66. 

de  Bruine  Ploos  Van  Amstel,  P.  J.  Samml  hlin. 
Vortr.,  1910,  Nos.  562-564,  page  194. 

Brik.     Mitt.  d.  Ces.  /.  inn.  med.,   Wein.  6  Marz,   1902. 

Cammidge,  P.  J.     Lancet,    1901,  II,  592. 

Cammidge,  P.  ].,  and  Garrod,  A.  E.  Jour,  of  Path 
and  Bacterial,    1900.   VI,  327. 

Cantmi-Cystinuria,  Obesity  &  Gall  Stones.  Trans,  from 
Italian   by  S.   Hahn,   Berlin,    1881,  p.    18. 

Chabrie.     Ann.  d.  mal.  d.  org.  gen-ur.,  1895,  XIII,  236; 

Church.     Trans.  Path.  Soc.  of  Lond.,  1869,  XX,  240. 

Civiale,      Medical   Treatment   of   Stone. 

Cloetta.     Liehig's   Ann.,    1856,   XCIX,   299. 

Cohn,   J.     Berl.  kUn.    Wchnschr.,    1899,   XXXVI,   503. 

Czapek.     Prager   med.    Wchmchr.,    1881.    p.    544. 

Delepine    {Proc.    Royal   Soc),    1890,    XLVII.    198. 

Des  Mouliers.      These  de  Paris.   1910-1911,   No.   328. 

Ebstein.  Deutsch.  Arch.  f.  klin.  Med.,  1879.  XXIII. 
138. 

Ebstein.  Reported  by  A.  Niemann.  Deutsch.  Arch.  f. 
klin.  Med.,   1876,  XVIII,  232. 

Ebstein.    Deutsch.  Arch.  f.  kVm.  Med.,  1881,  XXX.  594. 

Enwall.       Axel;     Case    reported    by    Santeson.    Hvgeia. 

1874.  XXXVI,  272.  .       3^=     . 

Fina    Lyson.      Brit.   Med.   Jour.,    1881,    I,    968. 

Fischer  and  Suzuki.  Zeitschr.  f.  Physiol.  Chem.  1905 
XLV,  405-411. 

Fowler.     Johns    Hopkins   Hospital  Reports,    1906,   XIII, 

557. 

Frankenthal,  Ludwig.  Deutsch.  Zeitschr.  f.  Chir.,  1914 
CXXXI,  442. 

Fromherz.  K.  Cystinuria.  Berl.  kUn.  IVchschr.,  1913, 
L.    1618-1620. 

Gamgee.     Lance/,    1901,   I,  470. 

Garrod,    A.    E.      Inborn   errors   of    Metabolism.      Lond 
1909.  pp.  82-135.     Cyslin. 

Garrod  and  Hurtly.     Jour,  of  Physiol.,   1906.  XXXIV. 

Gaskell.  J.  F.     Jour,  of  Physiol.,    1907,  XXXVI.    142 
Gaujot.     Progres  Med.,    1878.  VI.    184. 
Gilbert,   G.   A.      Chicago    Clin..    1900,   XII,    177. 
Gross,     W.     Sitzungsber.       Cesellsch.     f.     Morphol      u 
Physiol.,   1908.  XXIV.  97-101.  P    '■    "• 

Grutterink.  A.  Nederl.  Tijdschr.  V.  Cenee^..  1913. 
LVII.  I,  1877. 

Hall.     Quarterly  Med.  Jour..  1894.  p.  26. 

15 


Harnier,  W.  In  Neubauer  and  Vogel:  Anal\fse  dcs 
Harnes,    1876,    7th    ed. 

Harrison.  Reginald.     Brit.  Med.  Jour..    1879.  II,    10. 

Heath.  C.     BrU.  Med.  Jour.,   1875.   II.  613. 

Hele.  T.  Shirley.  Jour,  of  Physiol.,  1909.  XXXIX, 
52-72. 

Heller.  John.  Urinary  Concrelions  {Harnconcretionen) 
Wien.   1860.  pp.  67  and    145. 

Himmelstjerna.  Berl.  ^//n.  IVchnschr..  1899.  XXXVI. 
446. 

Hodann-Muller.      Ciinsburgs    Zeilschr.,    1851.    II,    264. 

von  Hofmann.  Karl.  Cenlralbl.  f.  d,  Crenzgeb.  d.  Med, 
u.  Chir.,   1907.  X.  721-730;   769-776. 

Hugounenq.     Li;on  MeJ.,   191 1 .  CXVII.  913. 

Ivanchich.      IVien.   Med.    IVchnschr.,    1869. 

Jacobson.  W.  H.  A.  Trans.  Clin.  Soc,  1891,  XXIV, 
155. 

Jeanbrau,   E.     Assoc,  franc,  d'urol..   1912,  XVI,  688. 

Johnson  in  Beale.  Urine  and  Urinary  Deposits  and 
Calculi.     2d  Lond..  1864.  p.  354. 

Jones,  Bence.  Trans.  Path.  Soc.  of  Land.,  1848-50,  II. 
237. 

Kleinschmidt.  Otto.  Urinary  Stones.  BerHn-Springer. 
1911. 

Kiemperer.  G.  and  Jacoby  M.  Therap.  d.  Cegenm. 
1914.  101-103.  Abst.  in  Jour.  A.  M.  A.,  1914,  LXII, 
1207. 

Kulz.     Zeihchr.  f.  Biol,  1884,  XX,  I. 

Kuttner.  Herman  and  Weil.  S.  Bieir.  Z.  l^lin.  Chir., 
1909,  LXIII,  364. 

Lafleur,    H.    A.      Phila.   Med.   Jour.,    1898.    I.    910. 

Lamy.     These  de  Nancy,    1911. 

Leo.     Zeilschr.  f.  klin.  Med.  Jour.,  1889,  XVI,  325. 

Lenoir,  cited  by  Civale,  p.  452. 

Leroy.  {d'Etoites)  Bull,  de  la  Soc.  d'anai.  de  Paris, 
1862.  VII.   331. 

Lewis,  M.  W.  and  C.  E.  Simon.  Amer.  Jour,  of  ihe 
Med.  Sc,  1902,  CXLIX,  p.  832. 

Loebisch.     W.     F.       Liebig's     Ann.     d.     Chem.,      1876, 

CLXXXII,  231. 

Loewy  and  Neuberg,  C.  Cystinuria,  Zeilschr.  f.  Physiol. 
Chem.,    1904-05,   XLIII,   338. 

Lichtenstern.      Wien.  klin.   Wchnschr.,   1903,  No.   18. 

Loumeau.  /.  de  Med.  de  Bordeaux,  1909,  XXXIX, 
795. 

Link,  Rudolph.  Cystinuria  and  Cystine  Stones.  Di-ss., 
Leipzig,    1912. 

MacPhail.      Bril.   Med.   Jour.,    1881.   I.  968. 

Magendie.  Research  Phys.  el  Med.  sur  les  causes  de 
la    Cravelle,  2d.   ed.,   Pans,    1818. 

Manby.  F.  E.     Cystine.     Brit.  Med.  Jour.,   1875.  I.  58. 

Marcet.  Essay  on  the  Chemical  History  and  Medical 
Treatment   of   Calculous   Disorders.      2d   ed.      Lond.,    1819. 

Marowsky.  Deutsch.  Arch.  f.  ^/in.  Med.,  1868,  IV. 
449. 

Marriot  and  Wolf.  Amer.  Jour,  of  Med.  Sci.,  1906,  p. 
197. 

Matrai.     Pesler  Med.  u.  Chir.  Preese,    1886. 

Mester.     Zeilschr.  f.  Physiol.,  Chem.,   1890.  XIV.    109. 

Moreigne.  Henrie.  Arch,  de  Med.  exp.  el  d'anai  Path., 
1899,  XI.  254. 

Momer.  Zeilschr.  f.  Physiol.  Chem.,  1899.  XXVIII, 
595. 

Morner,  K.  A.  H.  Zeilschr.  f.  Physiol.  Chem..  1901, 
XXXIV,  207. 

Morris,    H.      Lancet,    1906,    II,    141. 

Muller.     Arch.  f.  Pharm.,    1872.  LI.  p.   308. 

Muller.     Wien.  Med.  Wchschr..  1911.  LXI.  2363;  2487. 

Neill,    Hugh.      Loncet,    1831-1832,   I,   411. 

Neuberg  &  Mayer.  Zeilschr.  f.  Physiol.  Chem.,  1905, 
XLIV.  472. 

Neumann.     Berl.  ^/m.    Wchschr.,    1914,   LI,    1294. 

Ord.  W.  M.  Trans.  Path.  Soc.  Lond.,  1879-1880, 
XXXI.  384. 

Percival.   Alberto.      Clin.   Med.  Hal,    1902.   XLI,   50. 
16 


Pfeiffer.    Emil.      Centralhl.   f.   d.   Krankh.   d.   Harn-und 
Sexualorgane,    1894.   V.    187. 

Pfeiffer,  Emil.  Centralhl.  f.  d.  Krankh.  Harn-und 
Sexualorgane,    1897.   VIII.    173. 

Picchini  and  Conti.  Sperimantale,  1891,  No.  17.  Abslr 
Centralhl.  f.  kUn.  f.  Med.,    1892.   XVIII.   629. 

Poilatschek.  Mitt.  d.  Cessell.  f.  Inner.  Med.  Wien. 
Marz.,  6-1902. 

Prout.  Nature  and  treatment  of  stomach  and  Urinary 
affections.     3d,   ed.   Lond..    1840. 

Reid,  John.     yV.    Y.  Med.  Jour.,    1901.  LXXIII.  666. 

Riegler.  Wien.  me d.' Blatter,  1904,  No.  3.  Abstr 
Biochem.   Centralhl.,    1904,   II.  373. 

Rindflelsch.    Miinich,  med.  Wchmchr.,  1912,  LIX,  2250. 

Roberts.  Urmary  and  Renal  Diseases.  4th  ed..  Lea 
Bros.,   1885,  p.   111. 

Rothera,   C.   H.     ]our.  of  Physiol,    1904-05,   XXXII, 

Roberts,  William.  Med.  Times  and  Gazette,  1858, 
XVII,  626. 

Rumpel.  Archiv.  und  Atlas  der  Normalen  und 
Pathologischen  Anatomic. 

VM^'iof^"'"  ^'^'^'=^''-  f-  ^^P-  P'ith.  u.  Therap.,  1913, 
XIII,  326.  Fortschnitt  auf  d.  gebiete  der  Roenlgenstrahlen 
Ergdnzungsband,   10,  p.  39. 

Scherer.     Jahresber.  f.   Chem.,    1857,   561. 

Scholberg,   W.  A.  and  Garrod.     Lancet,    1901,   II,   526. 

Schossberger.      Wiirtemherg  Correspondent,   1857,  XXII. 

Schweig.      Med.   Ann.,   Heidelberg,    1848,    p.    364. 

Segaias.  Essay  on  Gravel  and  Stones.  2d  ed.,  1839, 
p.  85. 

Schaftock.  Trans.  Path.  Soc,  Land.,  1879-1880.  XXXI, 
183. 

.nni'"^;  ^*  ^'  Campbell  D.  Johns  Hopkins  Hasp.  Bull., 
1904,  XV,  365. 

Simon,  C.  E.     Amer.  Med.  Jour.  Sc.,  1900,  CXIX    39. 

Smith,  W.  G.     Practitioner,   1898,  LX,  475. 

Sondern,   F.     Arch,  of  Diagnosis,    1911,   IV.  267. 

Southam,   F.   A.     Brit.  Med.  Jour.,    1876.   II.   817. 

Southam.  F.  A.     Brit.  Med.  Jour.,    1907.   I,  489-490. 

Stadthagen.      Virchow's   Arch.,    1885,   C,   416 
1889^'^XXVi    344^""^    Brieger.       Berl.    ^/m.     Wchnschr., 

Stromeyer.     Ann.  of  Philosophy,    1824,   VIII,    146. 

Swarsensky.     Deutsch.  med.  Wchschr.,  1899,  XXV,  255. 

Strasser.     See   Brik. 

Thiele,  F.  H.      Trans.  Path.  Soc.  of  Land.,   1906-1907. 

*—>  V  illy    ^33* 

Thiele.  F.  H.     Jour,  of  Physiol.,   1907,  XXXVI,  68. 
Joel.  F.     Ann.  der  Chem.  u.  Pharmacie,    1855.  XCVI 
247. 

Thompson.  H.     Trans.  Path.  Soc.  of  Lond,  1870,  XXI, 

Thorndike,  P.  and  Ogden  J.  Bost.  Med.  and  Surg. 
Jour.,  1898,  CXXXVIII,  367. 

Udranszky.  L.  V.  and  Baumann,  E.  Zeitschr  f. 
Physiol.  Chem.,   1889,  XIII,  562. 

loH'^vvvli  ^o"/^^''    ^-       ■Deu'sc/i.     med.     Wchnschr., 
IVI3,  XXXIX,  2337. 

Venables,  R.  Quart.  Jour,  of  Science,  Literature  and 
Arts,   1830,  p.  30. 

Warburg.     Munch,  med.    Wchnschr.,    1898,   XLV,   766. 

Wasserthal.  Centalhl.  f.  Harn-und  Sexualorgane, 
1904,  p.    121. 

Wells,  H.  G.     Chem.  Path.  Phila.,    1914. 

Whitney,  W.  F.     Bost.  Med.  and  Surg.  Jour.,  1879,  CI, 

1909,  VI,  337. 

io^'"'*'.^V""^''y  Diseases  and  Their  Treatment.    Lond.. 
1838,  p.  109. 

Winternitz.     Prag.  Med.  Wchnschr.,  1910,  XXXV    64 

Wolf,   C.   G.   and   Shaffer.    P.   A.      Protein   Metabolism 

m   Cystmuria.     Jour.  Biol.   Chem.,    1908.    IV    440 

Wollaston.    W.    H.     Philos.    Trans.,   Lond..    1810.   223. 

Wood.  E.  S.     Bost.  Med.  and  Surg.  Jour.,   1879,  CI.  4. 

17 


PRIMARY      ADENO-CARCINOMA     OF 
THE  KIDNEY.* 

By   J.    S.    ElSENSTAEDT,    S.    B.,    M.   D.,    Chicago,    111.. 

Associate    Cenlio-Urinary    Surgeon    Michael    Reese 
Hospital. 

The  literature  is  replete  with  reports  both  of 
clinical  nature  and  histologic  research  of  primary 
cancer  of  the  kidney.  However  from  the  earliest 
data  at  my  disposal,  the  inaugural  dissertation  of 
Hullman  at  Halle,  published  in  1  849,  to  those  of 
very  recent  date,  I  have  been  impressed  by  the 
seeming  confusion  existing  in  the  histo-pathologic 
reports  made. 

Primary  carcinoma  of  the  kidney  is  included  in 
the  subject  material  in  all  the  standard  pathologies 
but  detailed  description  is  lacking  as  far  as  I  was 
able  to  determine.  The  tumor  which  we  have  under 
consideration  is  an  atypical  proliferation  of  the  se- 
creting cells  of  the  kidney,  in  many  places  showing 
exquisite  papillary  structure  and  as  such  can,  I 
believe,  only  be  considered  as  a  carcinoma  of 
adenomatous  type. 

The  confusion  in  the  literature  is  so  evident  that 
detailed  infringements  against  what  is  correctly 
termed  carcinoma  of  the  kidney  are  unnecessary  to 
this  discussion.  Suffice  it  to  say  that  hyperne- 
phroma, that  tumor  whose  place  is  still  so  indefinite 
in  pathology,  is  unquestionably  the  most  frequent 
lesion  which  has  been  incorrectly  classed  as  car- 
cinoma renis.  Papilloma  as  well  as  the  embryonic 
mixed  tumor,  or  kidney  blastoma,  otherwise  termed 
adeno-sarcoma,  of  Birch-Hirschfeld  have  repeated- 
ly been  described  under  cancer,  the  latter  usually 
as  carcinoma  of  the  kidney  in  childhood.  French 
authors  particularly  have  been  active  m  describing 
two  types  of  ''epitheliome  du  rein' — one  "a  cellules 
claires"  and  the  other  "a  cellules  sombres,"  which 
are  unquestionably  both  hypernephromata.  Albar- 
ran  and  Imbert  in  their  book  ''Tumeurs  du  Rein' 
published  in  1903,  emphasize  the  confusion  in  diag- 
nosis as  does  Kelynack.  It  is  not  my  intention  to 
attempt  to  clarify  the  very  turbid  ideas  of  histology 
relevant  to  kidney  tumors  and  particularly  concern- 
ing carcinoma,  neither  shall  I  enter  into  a  discussion 
of  the  origin  of  hypernephroma,  with  which  car- 
cinoma is  so  often  confused.  One  might  mention 
in  passing,  however,  that  while  Stoerk's  ideas  are 
beginning  to  get  a  foothold  here  in  America,  the 
pathologists  of  Austria  and  Germany  have  almost 
all  come  to  the  conclusion  that  Grawitz's  theory  of 
their  origin  is  the  more  tenable. 

As  regards  the  occurrence  of  primary  carcinoma 
of  the  kidney,  Garceau,  in  the  opening  chapter 
of  his  book,  states  that  carcinoma  of  the  pure  type 


*Read  before  the  American  Urological  Association.  North 
Central  Section,  Chicago,  November   12th,   1915. 


I  Reprinted    from    THE    I'ROLOGIC    AND    CUTANE- 
OUS REVIEW,  February,   1916.] 

18 


is  very  rare  and  that  the  tumor  most  often  found  in 
the  kidney  arises  from  suprarenal  rests.  In  going 
over  the  reports  of  the  Massachusetts  General  Hos- 
pital he  found  in  the  ten  years  preceding  1 909, 
hypernephroma  noted  thirty  times,  adenoma  four, 
carcmoma  three  and  sarcoma  twice.  Young  re- 
ports but  one  case  from  the  files  of  Johns  Hopkins 
Hospital.  The  Mayo  clinic  reports  three  cases  in 
the  past  ten  and  one-half  years.  McConnell  in  a 
statistical  report  on  deaths  from  carcinoma  in  the 
United  States  does  not  cite  a  single  instance.  Some 
of  the  older  reports  of  its  occurrence  are,  from  my 
viewpoint,  absolutely  unreliable,  however,  statistics 
have  been  compiled  by  Feilchenfeld  in  1901  — 
Reicheman  in  1902,  and  Redlich  in  1907.  Israel 
stated  that  the  tumor  is  found  more  often  in  the 
upper  pole  of  the  right  kidney.  Reiche  and  the 
Mayos  have  stated  that  malignancy  of  the  kidney 
is  dependent  upon  the  occurrence  of  nephrolithiasis 
and  in  fact  a  small  stone  was  found  in  one  of  the 
calices  in  the  kidney  under  discussion  and  showed 
plainly  in  the  Roentgen  plate.  Men  are  more  fre- 
quently affected  than  women,  and  the  few  authentic 
cases  occurred  in  patients  between  forty  and  sixty 
years  of  age.  Our  case,  as  you  may  see  from  the 
specimen,  is  the  right  kidney  from  a  man  forty-nine 
years  of  age.  The  patient  had  noted  hematuria 
four  years  previous  to  operation,  which  was  not  ac- 
companied by  pain  nor  by  any  other  general  symp- 
toms. Thereafter,  at  irregular  intervals,  there 
would  be  a  recurrence  of  blood  in  the  urine,  at 
times  the  free  intervals  lasting  from  several  months 
to  a  year.  Two  years  before  entering  the  hospital 
he  again  had  a  severe  attack  of  hematuria  and  at 
this  time  complained  of  a  burning  pain  in  the  penis 
during  urination,  and  a  dull  pain  in  the  right  lumbar 
region,  never  colicky  in  type.  From  then  on  till 
his  operation  his  condition  became  gradually  worse, 
the  free  intervals  being  reduced  to  weeks  and  the 
occurrence  of  bloody  urine  lasting  from  four  to  ten 
or  twelve  days.  This  history  suggests  to  me  that 
the  appearance  of  the  small  stone  in  the  kidney, 
in  all  probability,  followed  the  outset  of  the  tumor, 
and  probably  was  dependent  upon  the  presence 
of  the  tumor  rather  than  the  reverse.  The  patient's 
family  and  personal  history  aside  from  the  condi- 
tion m  hand,  is  entirely  negative. 

Urinalysis  as  follows  on  repeated  examinations: 

Color — Straw. 

Specific   Gravity— 1020-1028. 

Albumen. 

Sugar — Negative. 

Casts — Negative. 

Cells — 5-12    leucocytes   to   high-power   field. 

Few  erythrocytes. 
Cross  Pathology. — The  kidney  measures  twelve 
centimeters  in  length,  six  centimeters  in  width  and 
four  centimeters  in  thickness,  the  whole  organ  is 
of  a  purplish  red  color,  due  to  a  marked  passive 
congestion.     The  contour  of  the  kidney  as  a  whole 

19 


is  regular  and  normal,  with  the  exception  of  distinct 
fetal  lobulations  and  a  tumor  nodule,  measurmg 
four  centimeters  in  diameter,  situated  in  the  middle 
of  the  convexity  and  projecting  on  an  average  of 
one-half  centimeter  above  the  normal  surface.  This 
nodule  has  a  light  yellow  color  but  the  injected 
renal  capsule  covering  it,  lends  a  brownish  red 
shade  to  it.  Fine  striae  and  elevations  are  noted 
on  external  surface  of  the  whole  organ,  evidently 
due  to  secondary  contraction.  On  median  sagittal 
section  the  contour,  markings  of  cortex  and  me- 
dulla and  thickness  are  normal.  There  is  marked 
passive  congestion.     The  pelvis  is  slightly  dilated. 


Fig.  1. 

Magnification    75    diameters,    showing    the    papillary    structure    of    a    portion    of 
kidney  tumor.     Note  that  the  tubuH  show  no  hyperplastic  changes. 


and  the  mucosa  seems  fatty  and  distinctly  edema- 
tous. A  small  stone  three-fourths  centimeters  in 
diameter  is  lodged  in  one  of  the  calices.  On  sec- 
tion of  the  tumor  itself  it  was  found  to  be  roughly 
round  in  contour.  The  consistency  is  less  firm  than 
is  common  in  carcinomata  in  general.  It  is  uni- 
formly yellow  in  color  except  at  the  periphery  where 
hemorrhages  had  occurred.  These  later  areas  are 
yellowish  red  in  color  and  present  striae.  The  me- 
dian quadrant  of  the  tumor  mass  invades  the  pelvis. 
The  minute  pathology  of  the  tumor  is  to  me,  at 
least,  particularly  interesting.  As  you  will  note 
from    the    photo-micrographs    the    adenomatous    or 

20 


papillary  structure  is  striking  in  certain  areas,  while 
in  other  the  cells  are  arranged  in  massive,  compact 
aggregations.  The  photo-micrograph  showing  the 
renal  pelvis  demonstrates  to  the  left  the  massive  ar- 
rangement of  the  carcinoma  cells  and  from  this 
area  the  higher  magnification  of  two  hundred  and 
thirty  diameters  was  made,  while  to  the  extreme 
right  the  tumor  just  where  it  is  breaking  through 
the  pelvic  epithelium  shows  the  fine  papillary  struc- 
ture. The  submucosa  of  the  pelvis  is  greatly  thick- 
ened. The  papillae  are  characterized  by  very  slight 
amount  of  supporting  stroma  and  each  is  pierced 
centrally  by  a  capillary.      The  immediate  vicinity 


'm-'^mw 


Fig.  2. 

Magnification  70  diameters,  showing,  from  left  to  right,  massive  arrangement 
of  carcinoma  cells,  edematous  submucosa  of  renal  pelvis  and  to  the  extreme  right, 
papillary  arrangement  of   cells  and  breakmg   through   of   pelvic   epithelium. 


of  the  papillary  portion  of  the  tumor  shows  beau- 
tifully the  apparent  transformation  of  the  normal 
kidney  histology  to  carcinoma.  Some  of  the  glom- 
eruli are  but  slightly  changed,  some  show  changes 
of  hyperplastic  character  and  still  others  chronic 
fibrous  retrograde  changes.  In  those  showing  hyper- 
plasia, this  is  of  varying  degree  and  affects  both  the 
lining  and  secreting  cells.  In  those  with  retro- 
grade changes,  the  fibrosis  of  Bowman's  capsule  is 
present  in  all  degrees  of  advancement.  Some  of  the 
glomeruli  are  entirely  replaced  by  fibrous  tissue.  In 
some  of  the  glomeruli  in  the  zone  nearest  the  tumor 

21 


hyperplastic  changes  are  noted  in  the  tufts,  pre- 
senting all  gradations  from  practically  normal  glom- 
eruli to  tumor  acini.  The  cells  themselves  demon- 
strate marked  pleomorphism,  some  are  large,  swol- 
len and  show  mitotic  figures  m  the  nuclei.  The 
scantiness  of  supporting  stroma  is  again  noted  to 
be  striking.  The  cells  covering  the  papillae  are, 
for  the  greater  part,  what  might  be  termed  a  high 
cuboidal  type  and  resemble  closely  those  covering 
the  glomerular  tufts.  They  have  well  defined  nu- 
clei and  often  nucleoli.  The  cells  making  up  the 
more  solid  part  of  the  tumor  are  similar  save  that 
there  is  a  greater  proportion  of  protoplasm  to  nu- 
cleus.     They  show  practically  no  affinity   for   the 


%i. 


Fig.  3. 

Magnification  230  diameters  from  the  more  solid  portion  of  the  tumor.  Note 
lymph  vessel  plugged  with  carcinoma  ceils,  pleomorphism  of  cells  and  mitotic 
figures   in  nuclei   and  degenerated   renal   tissue. 

special  fat  stains.  Their  glycogen  content  as  de- 
termined by  the  lodin  test  is  very  small.  The  urini- 
ferous  tubules,  straight  and  convoluted  show  no 
transitional  changes.  The  higher  magnified  photo- 
micrograph, taken  from  the  more  solid  part  of  the 
tumor,  shows  very  nicely  a  lymph  vessel  plugged 
with  carcinoma  cells.  Watson  and  Cunningham  in 
figure  381  of  their  book  show  a  very  similar  tumor 
with  almost  identical  papillary  structures,  while 
a  photo-micrograph  of  the  same  tumor  under  higher 
magnification  might  readily  be  substituted  for  the 
one  I  have  just  described.  Their  illustrations  are 
of  a  kidney  tumor  in  the  pathological  department 
at  the  Boston  City  Hospital. 

22 


Two  types  of  carcinoma  of  the  kidney  are  de- 
scribed by  various  authors,  the  nodular  and  in- 
filtrating, the  latter  especially  by  Rokitansky.  Al- 
barran  in  his  enormous  experience  stated  that  he  had 
never  seen  one  of  the  infiltrating  type. 

As  to  the  origin  of  these  tumors  our  case  sug- 
gests that  they  may  arise  from  the  glomeruli  and 
such  a  case  has  been  described  by  Abram  in  the 
Journal  of  Pathology^  and  Bacteriology,  Edinburgh, 
Volume  VI,  page  384.  Others  are  of  the  opinion 
that  they  arise  only  from  the  uriniferous  tubules. 
Manasse  and  Lissard  for  example  have  stated  that 
they  were  able  to  show  that  the  tubules  became 
carcinoma  strands,  and  their  drawings  are  almost 
convincing.  Newman  in  1 896,  says  that  in  the 
neighborhood  of  the  advancing  tumor  the  epithelium 
of  the  uriniferous  tubules  had  taken  on  proliferative 
changes,  that  instead  of  being  granular  it  was 
clear,  and  that  the  tubules  were  lined  with  several 
layers  of  cells.  (He  quotes  Pereverseff  who  ap- 
parently started  the  idea  that  carcinoma  renis  must 
develop  from  the  uriniferous  tubule.)  Perever- 
seff, however,  while  publishing  on  carcinoma,  has 
actually  described  a  retroperitoneal  tumor  which 
secondarily  involved  the  lymphatics  of  the  kidney 
as  shown  by  von  Recklinghausen,  Weichselbaum 
and  Greenish  also  state  that  carcinoma  of  the  kid- 
ney arises  from  the  normal  parenchymal  epithelium, 
and  transition  of  the  uriniferous  tubules  into  car- 
cinoma. Waldeyer  and  Thiersch  agree  with  the 
above.  Lissard  found  changes  in  the  straight  tu- 
bules as  well  as  in  the  tubuli  contorti  and  concluded 
that  in  his  case  the  tumor  arose  from  both.  The 
glomeruli,  he  says,  show  little  of  interest.  Hektoen, 
of  this  city,  in  the  American  Text  Book  of  Path- 
ology, says  that  cancer  of  kidney  may  develop  from 
tubular  epithelium  as  adeno-carcinoma.  While  this 
discussion  is  of  course  of  academic  interest  it  would 
lead  us  too  far  to  quote  other  expressions  of  opinion 
regarding  their  histogenesis.  However,  the  follow- 
ing note  recently  came  to  my  notice,  that  m  the  ex- 
amination of  hundreds  of  kidneys  of  cats  and  dogs, 
50  per  cent,  showed  proliferation  of  the  epithelium 
of  the  tubuli  contorti  into  the  capsule  of  the  glom- 
erulus and  this  may  be  readily  imagined  by  glanc- 
ing at  the  normal  histology  of  the  secreting  ap- 
paratus. That  carcinomata  may  arise  from  the 
minute  adenomata,  so  often  found  in  kidneys  show- 
ing secondary  contraction  is  quite  generally  ac- 
cepted. Orth  says  "auch  an  der  niere  besleht 
lieine  scharfe  Crenze  zwischen  adenomen  and  car- 
cinomen,  denn  man  siehi  in  manchen  Ceschtvulsten, 
neben  Driisenschlduchen  mil  lumen,  soUde  Kolben 
und  Zellhaufen  in  die  Alveolen  eingelagert,  also 
nicht  mehr  das  Bild  eines  Adenoma  sondern  das, 
des  Carcinoms.''  Stoerk  goes  still  further  and  states 
that  all  epithelial  tumors  of  the  kidney,  from  the 
small  multiple  adenoma  to  the  Grawitz  type  are 
variations  of  the  same  process  and  neoplastic  de- 
velopment.      Legueu    says    that    adeno-carcinoma 

23 


shows  the  transformation  of  a  benign  tumor  into  a 
mahgnant  one  and  also  the  possibihty  of  renal  epi- 
thelium to  transform  itself  into  carcinoma.  I  he 
papillary  arrangement  is  dependent  upon  cyst  for- 
mation, however  minute.  Von  Hanseman  says  that 
the  primary  cyst  develops  from  a  uriniferous  tubule 
or  Bowman's  capsule  and  the  papillae  about  small 
blood  vessels.  The  fact  that  any  cyst  formation 
in  the  kidney  as  well  as  elsewhere  may  lead  to 
papillary  growths  has  been  noted  repeatedly  in 
careful  studies  of  congenital  cytsic  kidneys.  The 
patient  was  operated  by  Dr.  Kolischer,  to  whom 
I  am  indebted  for  the  specimen,  on  March  9,  1915, 
and  left  the  hospital  on  March  11,  1915,  in  good 
condition.  He  has  been  in  good  condition  to  the 
present  date.  The  life  expectancy  in  these  cases 
following  operation  is  usually  short  because  rarely 
a  diagnosis  is  made  before  metastasis  has  occurred. 
In  the  three  cases  operated  at  the  Massachusetts 
General  Hospital  one  survived  twenty-two  days,  a 
second  four  months  and  the  third  one  year.  Al- 
barran  in  his  enormous  experience  only  operated  two 
early  cases,  one  of  the  kidneys  removed  showed  no 
visible  nor  palpable  deformity  but  on  section  a 
small  carcinoma  appearing  like  a  focus  of  tuber- 
culosis. The  other  case  had  been  operated  for 
stone  when  Albarran  noted  a  slight  elevation  from 
the  niveau.  On  section  a  small  vascular  non-en- 
capsulated tumor  was  exposed  which  invaded  the 
parenchyma  and  was  the  size  of  a  cherry. 

In  conclusion,  this  case  presents  several  points  of 
interest — first,  the  long  duration  of  hematuria  not 
accompanied  by  pain  or  other  general  symptoms, 
then  followed  in  two  years  by  pain  associated  with 
hematuria  probably  due  to  the  small  stone  found 
in  one  of  the  calyces.  Secondly,  the  general  well- 
being  of  the  patient  seven  months  after  operation. 
Thirdly,  the  rather  unusual  histo-pathology  sug- 
gesting that  the  tumor  arose  from  the  glomeruli 
rather  than  the  uriniferous  tubules.  Fourth,  its 
rarity  as  suggested  by  the  scant  reports  of  authentic 
cases  in  the  literature. 

The  tumor  is  not  a  malignant  papillary  adenoma 
of  the  type  described  by  Sudeck,  Bentley  Squier, 
Kretschmer  and  myself,  nor  can  it  possibly  be  con- 
fused with  tumors  of  the  Grawitz  type. 

DISCUSSION. 

Dr.  H.  L.  Kretschmer:  The  patient  we  reported  a  year 
and  a  half  ago,  and  to  whom  Dr.  Eisenstaedt  referred,  oc- 
curred in  a  young  man  of  19.  The  specimen  was  obtained 
at  post-mortem.  The  patient  had  among  many  other  in- 
teresting things  a  large  deposit  of  lime  salts  which  gave 
a  shadow  which  resembled  the  presence  of  a  large  stone. 
Our  specimen  showed  infiltration  with  lime  salts  in  the  old 
parts  of  the  tumor  as  well  as  in  the  metastases.  I  have 
never  seen  reports  of  these  general  lime  deposits  in  these 
rare   types   of   tumors. 

I  do  not  believe  I  understood  Dr.  Eisenstaedt.  Did  you 
say  the  tumor  was  an  adenocarcinoma,  but  of  the  papillary 
type  ? 

Dr.  D.  N.  Eisendrath:  The  specimens  are  of  unusual 
interest.     They  show,  as  he  said,  that  they  are  not  malignant 

24 


adenoma  of  the  papillary  type;  that  they  are  primarily 
adenocarcinoma.  There  are  a  number  of  interesting  fea- 
tures about  the  cases.  The  clinical  point  about  the  inter- 
mittent hematuria  is  of  great  interest.  Why  these  tumors 
should  at  times  open  into  the  pelvis  of  the  kidney  and 
then  close  again  is  of  considerable  importance  as  far  as 
the  diagnosis  is  concerned.  I  had  this  past  summer  an 
enormous  hypernephroma  in  which  at  no  time  had  any 
hematuria  been  present.  There  was  another  symptom  that 
I  had  met  for  the  first  time,  namely,  that  every  time  this 
patient  had  a  hemorrhage — we  did  not  know  what  had 
taken  place  until  the  autopsy — he  had  a  reflex  renal  ileus, — 
enormous  distension  of  the  abdomen,  vomiting,  pain- 
symptoms  that  looked  like  typical  impacted  stone  in  the 
ureter.  I  will  report  the  case  this  coming  winter  as  one  of 
reflex  renal  ileus.  They  are  sometimes  taken  for  appendi- 
citis or  intestinal  obstruction.  At  autopsy  about  two-thirds 
of  the  hypernephroma  was  found  to  be  composed  of  blood 
clot. 

Another  point  was  brought  out  by  Dr.  Kretschmer  and 
Dr.  Eisenstaedt  that  we  must  take  into  consideration  in 
the  differential  diagnosis  renal  shadows.  I  saw  this  last 
spring  a  marked  case  at  the  Jefferson,  and  also  again  Dr. 
Louis  Schmidt  had  a  case  from  Kansas  City,  namely, 
calcification  taking  place  in  a  malignant  tumor,  simulating 
the   shadow   of   a   recent  calculus. 

In  regard  to  the  origin  of  these  tumors,  from  the 
glomeruli  or  the  tubules,  I  do  not  know  whether  you  know 
of  the  work  of  Berner  of  Copenhagen,  who  has  written  a 
volume  on  cystic  kidney,  and  his  views  are  beginning  to  be 
accepted,  that  congenital  cystic  kidneys  are  due  to  the  fact 
that  there  is  a  failure  of  union  of  portions  of  the  kidney 
which  are  to  form  the  glomeruli  and  the  collecting  tubules; 
that  the  collecting  tubules  are  formed  from  ingrowths  of 
the  ureter  and  that  these  are  primarily  deposits  of  em- 
bryonal cells  which  do  not  meet  each  other,  with  cyst 
formation.  If  seems  plausible.  It  seems  to  me  about  as 
likely  a  theory  to  explain  these  primary  adenocarcinomata 
as  we  can  think  of.  Instead  of  being  retention,  some  one 
portion  of  the  kidney  has  not  united  with  its  distal  portion 
and  has  undergone  proliferation  and  the  formation  of  an 
adenocarcinoma.  The  case  is  certainly  of  great  interest, 
and  I  think  we  all  feel  indebted  for  such  a  thorough  pre- 
sentation of  it. 

Dr.  Eisenstaedt  (m  closing)  :  The  reason  for  my 
attempt  to  go  thoroughly  into  the  histopathology 
of  this  case  is  the  fact  that  several  years  ago 
while  working  with  Professor  Pick  of  Berlin  I  had  the 
opportunity  of  studying  and  reporting  a  malignant  papilloma 
of  the  kidney  in  which  the  papillae  were  clothed  with  a 
single  layer  of  cells  throughout.  The  many  metastases 
present  in  this  case  also  demonstrated  that  the  papillae  there- 
in were  likewise  covered  with  but  a  single  layer  of  cells. 
Histopathologically  one  could  not  differentiate  it  from  a 
benign  tumor.  Clinically  it  .of  course  was  extremely  ma- 
lignant and  presented  widespread  metastases.  This  is  in 
marked  contradistinction  to  the  case  under  consideration  this 
evening  which  is  so  plainly  carcinoma.  The  origin  of  the 
tumor  is  interesting.  If  one  bears  in  mind  the  histology  of 
the  secreting  apparatus  one  will  see  that  the  slight  dis- 
placement of  any  of  the  cells  and  the  sfimulous  to  a  wild 
proliferation  would  entangle  the  matter  even  worse  than 
it  is  at  present  and  leave  us  in   the  dark  as  to  its  origin. 


25 


RADIOTHERAPY    AND    DIATHERMY 

IN  MALIGNANT  TUMORS  OF 
THE    BLADDER.^ 

By  G.   Kolischer,  Chicago,   111., 

Attending   Surgeon   to   the   Cenito- Urinary   and   Radiothera- 

peutic    Department    of    the    Michael    Reese 

Hospital   in    Chicago. 

It  seems  that  now  the  radiotherapy  of  mahgnant 
bladder  tumors  and  its  auxihary  forces  may  be 
practiced  and  developed  along  well  defined  lines. 
We  are  now  in  possession  of  tangible  results,  the 
analysis  of  which  indicates  certain  directions. 

It  may  be  stated  right  now  that  the  X-rays 
though  filtered  and  penetratmg  are  without  any 
definite  curative  value.  Generally  the  effect  of  the 
X-rays  will  be  a  certain  cleaning  up,  that  is  the 
cystitis  usually  accompanymg  the  presence  of  a 
malignant  tumor  will  disappear,  a  sick  tumor  will 
acquire  under  their  influence  a  less  angry  appear- 
ance, hemorrhages  and  pains  will  subside  for  some 
length  of  time.  But  in  no  instance  could  a  dis- 
appearance or  even  an  appreciable  shrinkage  of  the 
growth  be  observed. 

It  seems  also  very  doubtful,  whether  the  exclu- 
sive application  of  X-rays  is  of  pronounced,  value 
in  preventing  recurrence  after  a  resection  of  the 
bladder  for  malignancy. 

The  endovesical  application  of  mesothorium,  how- 
ever, furnishes  results  of  an  entirely  different  char- 
acter. We  are  having  now  on  our  records,  four 
cases  of  inoperable  cancer  of  the  bladder  to  attest 
to  this  statement. 

In  three  of  these  cases  we  are  in  a  position  to 
verify  our  results  by  repeated  local  examinations, 
while  in  the  fourth  case  on  account  of  the  patient's 
attitude  the  verification  of  the  improvement  attained 
can  only  be  gleaned  by  clinical  observation. 

The  first  case  to  be  recited  was  turned  over  to 
the  department  by  L.  E.  Schmidt,  as  cancer  occupy- 
ing practically  the  whole  lower  half  of  the  bladder 
about  eleven  months  ago.  Under  mesothorium 
treatment  rapid  improvement  set  in  so  that  a  cysto- 
scopy undertaken  by  Schmidt  seven  months  ago  re- 
vealed the  bladder  positively  clear  save  for  a  little 
papillomatous  nodule  near  the  left  ureter.  This 
was  fulgurated  by  the  doctor.  A  cystoscopy  ex- 
ecuted a  few  days  ago  showed  the  bladder  to  be 
absolutely  normal,  no  trace  of  any  pathology.  The 
next  case  also  coming  out  of  the  practice  of  Schmidt 
was  a  cancer  of  the  trigonum  involving  the  whole 
circumference  of  the  internal  orifice.  First 
mesothorium  treatment  eight  months  ago.  A  cysto- 
scopy made  by  me  and  Schmidt's  associate  four 
weeks   ago  revealed   the   bladder   free   save   for   a 


*Read  before  the  American  Urological  Association,  North 
Central   Section,  Chicago,   November    12th,    1915. 


IHeniintecl    from    THK   UROLOGIC    AND    CUTANE- 
OUS REVIEW,   February,   1916.] 

26 


nodular  but  epithelialized  tumor  of  the  size  of  a 
pigeon's  egg  in  the  left  border  of  the  trigonum. 
The  general  condition  of  the  patient  is  now  excel- 
lent. The  third  case  is  a  trigonal  cancer  growing 
out  of  the  bed  of  a  removed  prostate.  Two  months 
ago  the  patient  began  to  be  distressed  by  bloody 
dysuria  and  pains.  It  was  impossible  to  pass  any 
instrument  through  the  posterior  urethra.  Supra- 
pubic cystotomy  was  resorted  to  and  the  diagnosis 
of  an  extensive  cancer  of  the  trigonum  was  estab- 
lished. Mesothorium  treatment  resulted  in  mak- 
ing the  bladder  basin  smooth  and  at  the  present 
time  French  27  may  be  easily  passed.  Our  inten- 
tion is  to  let  the  abdominal  fistula  close  up  and  to 
continue  the  treatment  per  urethram. 

The  fourth  case,  again  one  of  Schmidt's,  had 
an  extensive  cancer  of  the  trigonum  with  very  dis- 
tressing subjective  symptoms.  Mesothorium  im- 
proved the  patient  locally  and  generally  to  such  an 
extent  that  he  not  only  refused  further  treatment 
but  even  an  examination. 

For  application  per  urethram  the  Mesothorium  is 
enclosed  in  a  gold  filter,  for  application  through 
a  suprapubic  opening  it  is  placed  in  a  silver  or  brass 
container. 

In  order  to  give  the  patient  all  the  benefit  of 
the  appliances  at  our  command  we  are  using  the 
mixed  crossfire,  that  is  the  patient  is  also  treated 
with  filtered  X-rays  abdominally  while  the  Meso- 
thorium is  still  inside  of  the  bladder  or  shortly 
after  the  Mesothorium  application. 

As  to  the  auxiliary  forces  employed,  we  are 
making  it  a  practice  to  inject  parallel  to  the  actino- 
therapy  cancer  extracts  into  the  patients.  Occasion- 
ally we  observed  local  reactions  which  may  have 
led  to  sensitizing  of  the  tumors,  but  we  are  under 
the  impression  that  since  we  have  employed  these 
extracts  we  did  not  any  more  provoke  any  dissem- 
ination of  mestastases. 

While  we  prefer  to  place  the  Mesothorium  into 
the  non-opened  bladder  incidental  indications  may 
arise  that  call  for  cystotomy,  as  such  I  will  quote 
the  necessity  of  speedily  relieving  the  patients'  suf- 
fering, retention,  hemorrhage  and  urosepsis.  In 
dealing  with  the  tumors  after  the  bladder  is  once 
opened  we  consider  the  coagulation  of  the  tumor 
by  diathermy,  a  very  valuable  adjuvant.  By  this 
method  the  hemorrhages  are  stopped,  infectious  mat- 
ter is  destroyed  and  the  tumor  is  reduced  to  a 
leathery  crisp.  In  this  way  the  deeper  layers  be- 
come more  accessible  to  the  rays. 

We  want  it  distinctly  understood  that  we  do  not 
claim  to  eradicate  a  tumor  by  this  procedure  but 
we  consider  it  only  a  preparatory  step,  although  one 
of  great  value. 


CHRONIC   EDEMA  OF   THE   VESICAL 
NECK.* 

Bv   Henry  J.   Scherck,   M.   D.,  F.   A.  C.   S. 

That  an  edema  of  more  or  less  extent  of  the 
vesical  neck  is  often  superimposed  on  an  enlarge- 
ment of  the  prostate  I  feel  certain  is  often  the  case, 
as  I  shall  further  emphasize  a  little  later,  but  the 
occurrence  in  three  cases  of  an  edema  of  a  chronic 
type  sufficient  in  extent  to  produce  all  the  symptoms 
both  objective  and  subjective  that  are  met  with  in 
cases  of  simple  hypertrophy  of  the  prostate  gland  is 
my  postulate  and  offers  sufficient  excuse  for  the 
presentation  of  this  report.  A  synopsis  of  the  his- 
tory of  the  first  case  follows: 

The  patient,  Edward  Burke,  aged  70,  was  as- 
signed to  my  service  on  February  15,  1915,  and 
from  the  history  written  at  that  time  and  subse- 
quent to  the  operation,  the  following  notes  have 
been  made  which  seem  essential  for  the  considera- 
tion of  the  case. 

The  patient's  complaints  on  admission  were: 
First,  swelling  of  the  feet  for  the  past  month  or  so ; 
second,  difficulty  in  urination  for  past  year,  has  had 
to  be  catheterized  occasionally ;  third,  attacks  of  in- 
flammatory rheumatism ;  fourth,  hemorrhoids. 

Physical  Examination. — A  poorly  nourished  man 
who  seems  to  be  in  no  particular  distress.  Systolic 
murmur  heard  at  aortic  area,  second  aortic  accen- 
tuated. Abdomen  normal,  with  exception  of  an 
inguinal  hernia  of  the  right  side;  extremities  slightly 
edematous.  All  else  negative  with  exception  of 
the  bladder  condition.  On  being  transferred  to  my 
service  I  copy  the  following  notes  made  by  my  in- 
terne. "Patient  transferred  to  the  urological  ser- 
vice of  Dr.  Scherck  on  account  of  urinary  disturb- 
ance, his  chief  complaint  is  that  he  is  unable  to 
voluntarily  void  his  urine,  and  catheterization  has 
to  be  resorted  to" — gives  the  history  of  having  had 
to  urinate  frequently  for  about  a  year — most 
noticeably  at  night.  States  the  trouble  has  existed 
for  at  least  two  years.  The  history  is  again  gone 
into  very  carefully  in  regard  to  all  details  but  which 
have  no  particular  bearing  on  the  subject  under  dis- 
cussion, hence,  omit  same.  The  diagnosis  at  this 
time,  according  to  the  history  which  was  written 
before  my  examination  of  the  patient  was,  as  fol- 
lows: 1st.  Hypertrophied  prostate;  2,  Mitral 
regurgitation;  3,  Aortic  stenosis;  4,   Bronchitis. 

Examination  by  me  of  the  local  condition  showed 
the  prostate  prominent  by  rectal  examination ;  tumor 
about  the  size  of  a  lemon,  extremely  hard,  cysto- 
scopic  examination  reveals  a  bottle-neck  projection 
into  the  bladder,  no  calculi.  Diagnosis,  hyper- 
trpphy  of  the  prostate,  prostatectomy  indicated  pro- 


*Read  before  the  American  Urological  Association,  North 
Central   Section,  Chicago,   November    12th,    1915. 


[Reprinted    from    THE   UROLOGIC   AND   CUTANE- 
OUS REVIEW.  February,  1916.] 

28 


vided  general  condition  of  patient  can  be  improved. 
After  about  a  month  of  preparation  during  which 
time  comp>ensation  was  estabHshed  and  general  con- 
dition much  improved,  kidneys  showing  a  satisfac- 
tory phenotallin  output  he  was  operated  on  as  men- 
tioned in  the  beginning  of  this  account  on  March 
19,  1915,  in  the  presence  of  quite  a  gath- 
ering of  local  members  of  the  profession.  A 
suprapubic  incision  was  made  in  the  bladder, 
the  operator  introducing  his  finger  directly 
therein,  remarked  "the  tumor  is  disappearing  under 
my  fingers."  Dr.  Klippel,  my  assistant,  was  told  to 
introduce  his  fingers  immediately,  and  substantiated 
the  fact  that  the  tumor  was  gradually  disappearing. 
In  not  more  than  ten  minutes  there  was  no  projec- 
tion of  the  tumor  into  the  bladder,  and  the  finger 
of  the  operator  could  be  introduced  well  into  the 
prostatic  urethra.  The  prostate  gland  was  not  in- 
terfered with,  as  there  seemed  to  be  no  further  in- 
dication. The  wound  was  closed,  bladder  drained, 
patient  returned  to  the  ward.  He  made  an  unin- 
terrupted recovery,  and  in  four  weeks  the  suprapubic 
wound  had  healed.  By  this  time  urinary  function 
had  returned  and  was  practically  normal. 

He  was  discharged  from  the  hospital,  and  noth- 
ing was  heard  of  him  for  about  three  months,  when 
he  again  returned  presenting  all  the  symptoms  that 
he  had  complained  about  on  his  first  admission.  He 
was  again  cystoscoped  and  again  an  intravesical 
projection  could  be  easily  seen.  By  rectal  ex- 
amination a  hard  mass  could  again  be  felt  in  the 
position  of  the  prostate;  this  mass  was  particularly 
hard  and  unyielding,  decidedly  more  so  than  is 
ordinarily  felt  in  cases  of  simple  hypertrophy.  Ca- 
theterization was  again  resorted  to  as  he  was  unable 
to  voluntarily  void  his  urine.  Such  is  a  brief  his- 
tory of  this  particular  case.  Since  this  case  was 
first  seen,  I  have  had  occasion  in  the  course  of 
my  prostatic  work  (and  having  this  case  in  mind) 
to  notice  that  in  two  others  on  operating  for  hy- 
pertrophy of  the  prostate  that  after  the  bladder 
had  been  opened  and  waiting  for  a  short  time  that 
the  tumor  mass  decidedly  diminished.  In  both  of 
these  cases,  however,  the  prostates  were  sufficiently 
enlarged  to  warrant  their  being  shelled  out,  but 
they  served  to  show  beyond  question,  that  an  edema 
of  the  vesicle  neck,  either  associated  or  unassociated 
with  hypertrophy  of  the  prostate  can  cause  obstruc- 
tion. Surely  many  of  us  have  been  surprised  how 
small  removed  glands  sometimes  are,  contrary  to 
our  expectations.  I  have  endeavored  in  a  number 
of  cases  by  means  of  an  instrument  devised  by  me 
(The  Prostatometer  vi'Je /.  A.  M.  A.,  July,  1914) 
to  approach  at  an  estimation  of  the  rela- 
tive diameter  of  the  prostate  between  the 
bladder  and  the  rectum  as  compared  with  the  diam- 
eter of  the  prostate  after  removal  and  find  it  is  fre- 
quently 3  or  4  times  as  great  before  as  I  do  upon 
exzimination  of  the  specimen  after  removal.  Of 
course,  much  of  this  discrepancy  can  be  accounted 

29 


for  by  thd  tissues  overlying  and  underlying  the  gland 
itself,  but  I  am  confident  that  there  must  exist  in 
many  cases  an  edematous  condition. 

It  occurs  to  me  that  on  account  of  the  compres- 
sion exercised  by  the  fibrous  covering  of  the  gland 
as  the  prostate  enlarges  either  as  a  result  of  inflam- 
matory conditions,  ordinary  hypertrophy,  arterial 
sclerosis,  that  an  edema  even  unassociated  with  a 
typical  adenomatous  hypertrophy  can  occur.  The 
explanation  for  the  subsidence  of  the  edema  in  the 
cases  which  I  have  mentioned  can  be  explained 
as  a  direct  result  of  the  depletion  due  to  the  incision 
into  the  bladder.  With  this  thought  in  mind,  the 
good  result  in  some  of  the  cases  which  follows  the 
punch  operation,  as  suggested  originally  by  Mercier 
and  later  by  Young,  can  be  accounted  for  by  the 
relief  of  a  chronic  edema.  In  properly  selected 
cases,  those  which  are  variously  diagnosed  as  fibrous 
constriction  at  the  neck  of  the  bladder,  so-called 
middle  lobe  enlargement  of  moderate  degree,  may 
possibly  be  associated  with  an  edema  and  thus  re- 
lieved by  an  operation  which  among  its  results  un- 
questionably is  a  depletion  without  removal  of  the 
gland.  I  have  hurriedly  scanned  the  literature  and 
find  very  little  reference  to  this  condition  in  the 
ordinary  text-books,  or  in  the  current  medical  lit- 
erature. However,  John  B.  Deaver,  in  his  work  on 
enlargement  on  the  prostate,  its  diagnosis  and  treat- 
ment, on  page  77,  edition  of  1905,  says:  "Very 
great  impairment  of  the  urinary  function  may  result 
when  there  is  no  apparent  mechanical  obstruction. 
In  such  cases  the  cause  of  the  trouble  is  existence 
of  a  hard  edema  (I  had  noticed  the  extreme  hard- 
ness of  the  gland  in  the  case  reported),  such  pro- 
cesses, the  result  of  long  preceding  congestions  or 
chronic  inflammations,  render  the  normally  soft  and 
pliable  vesical  outlet  firm  and  rigid,  so  that  the  pros- 
tatic urethra  can  no  longer  open  up  into  practical 
continuity  with  the  bladder  during  urination,  as  a 
consequence  obstruction  arises  from  the  immobility 
of  the  parts.  In  such  cases  the  prostate  itself  may 
be  little  or  not  at  all  enlarged." 

In  speaking  of  this  case,  to  Dr.  Kolischer  at 
the  time,  I  am  under  the  impression  that  he  had  on 
a  former  occasion  called  attention  to  this  condition. 
This  case  was  of  particular  interest  to  me,  and 
is  reported  for  what  it  is  worth.  I  should  like  to 
hear  from  Dr.  Kolischer,  who  may  be  able  to  give 
us  some  further  observations  on  the  subject. 


30 


A    VERY    UNUSUAL    CASE    HISTORY 

PRESENTING    AMONG    OTHER 

FEATURES     A     CYSTO- 

SCOPIC  BURN.^ 

Bv    F.    R.    Charlton,    M.    D.,    Indianapolis,    Ind. 

Dr.  Simon  J.  Young  called  me  in  November, 
1912,  m  a  case  supposedly  renal  m  character.  The 
man,  twenty-eight  years  of  age,  had  ten  years  be- 
fore suffered  from  right  renal  colic.  The  X-ray 
was  said  to  have  shown  a  stone  and  nephrotomy 
was  done.  Suppuration  ensued  and  nephrectomy 
followed.  The  patient  recovered  and  remained 
practically  well  until  1912.  Left  lumbo-abdominal 
pains  then  developed  and  increased  steadily  in  se- 
verity. The  patient  thought  he  had  passed  two 
small  stones  by  the  urethra.  The  attacks  of  pain 
became  so  severe  that  morphine  failed  to  relieve  and 
mild  chloroform  anesthesia  was  maintained  from 
thirty  to  sixty  minutes  before  relief  was  obtained. 
These  measures  were  resorted  to  on  repeated  oc- 
casions. The  pain  began  in  the  left  lumbar  region 
and  radiated  downward  and  forward  toward  the 
pubes.  There  was  no  rise  in  temperature.  Often 
a  suppression  of  urine  would  accompany  and  per- 
sist for  twelve  hours.  The  patient  was  otherwise 
in  splendid  physical  condition  and  to  quote  his  wife, 
"ate  enormously."  The  bowels  were  regular. 
Physical  examination  and  urinary  studies  revealed 
nothing.  Radiographs  of  the  kidney  were  nega- 
tive with  and  without  resort  to  pyelography.  X-ray 
studies  of  the  intestinal  tract  made  by  Dr.  Cole 
brought  what  we  believe  to  have  been  the  solution 
to  our  dilemma.  A  glance  at  the  radiograph  will 
show  you  an  enormous  sigmoid,  which  if  uncoiled, 
would  approximate  three  feet  in  length  and  reaches 
a  position  well  to  the  right  side  of  the  abdomen  con- 
siderably above  the  umbilicus.  It  descends  toward 
the  left  lower  quadrant  where  it  terminates  in  a 
kink  at  its  junction  with  the  colon.  A  second  con- 
striction IS  apparent  near  its  terminal  portion.  This 
is  probably  due  to  an  adhesion. 

The  diagnosis  was  colonic  stasis  contributed  to 
by  an  almost  unbelievable  gluttony. 

The  patient  was  placed  on  a  greatly  restricted 
diet  and  hygienic  measures.  Since  this  plan  was 
adopted  he  has  had  no  pain  save  slight  attacks  that 
invariably  follo\ved  his  breaking  away  from  his 
diet  and  overeating.  Good  behavior  entirely  con- 
trolled the  situation.  The  above  is  from  notes  by 
Dr.  Young. 

While  doing  ureteral  catheterization  a  short  cir- 
cuit was  established  with  evidently  a  true  cataphore- 
sis.  There  resulted  a  burn  of  the  second  degree 
nearly  an  inch  in  diameter  immediately  surround- 


*Read  before  the  American  Urological  Association,  North 
Central  Section,  Chicago,   November    12th,    1915. 


[Reprinted    from    THE    UROLOGIC    AND    CUTANE- 
OUS REVIEW,  February,   1916.] 


31 


Enormous    distention    of    sigmoid. 


32 


ing  the  meatus.  The  patient  complained  of  a 
smarting  sensation  but  not  emphatically  enough  for 
us  to  realize  what  we  were  doing.  The  appearance 
was  of  a  greenish-black  eschar  such  as  might  occur 
in  a  third  degree  burn.  This,  however,  was  super- 
ficial zmd  we  felt  warranted  in  assuming  that  the 
discoloration  was  due  to  a  copper  cataphoresis  in- 
duced at  the  shoulder  of  the  cystoscope.  Healing 
took  place  without  a  scar  and  we  congratulated 
ourselves  on  such  a  termination  in  the  only  accident 
of  its  kmd  that  we  have  seen. 

I  ask  just  a  moment  further  to  show  the  roent- 


Fig.  2. 

Roentgenogram    of    a    kidney    in    which    pyelography 
was   followed   by   death. 


genogram  of  a  kidney  where  death  followed  pyelog- 
raphy. The  case  was  reported  at  Philadelphia  and 
Atlantic  City  in  1914,  but  the  plate  was  not  shown. 
The  individual  had  a  tumor  mass  the  size  of  a 
small  grape  fruit.  I  made  no  examination,  simply 
being  called  by  Dr.  E.  D.  Clark,  the  surgeon  in 
charge,  to  do  pyelography.  Fifteen  c.c.  of  a 
twenty-five  per  cent,  solution  of  collargol  was  used 
with  a  hand  syringe,  the  idea  then  prevailing  and 
still  being  adhered  to  by  some  eminent  men,  that 
a  catheter  would  not  so  block  the  ureter  but  that 
excess  of  fluid  would  find  its  way  back  along  the 
course  of  the  ureter.      Such  an  assumption  proves 

33 


not  to  be  a  safe  one,  as  is  evidenced  by  this  case. 
There  was  some  distress  toward  the  close  of  the 
injection  but  it  was  not  so  extreme  as  to  cause  us 
to  suspend  our  efforts  toward  securing  a  good  plate. 
This  we  were  able  to  do.  The  patient  quickly 
went  into  a  state  of  shock  and  died  eight  hours 
later.  Hemorrhage  may  have  followed  the  rup- 
turing of  some  diseased  vessel  but  even  if  so,  it 
would  hardly  be  a  vessel  of  such  size  as  to  produce 
the  almost  instantaneous  shock  that  supervened  here. 
Necropsy  was  not  secured.  Granting  that  I  had 
produced  some  small  rupture  in  the  pelvis,  I  could 
hardly  see  why  death  should  have  followed  so 
promptly  unless  from  extensive  hemorrhage.  The 
patient  had  an  irregular  heart  action  and  an  almost 
cyanotic  color  prior  to  this  so  that  we  at  the  time 
looked  upon  the  death  as  probably  due  to  a  bad 
myocardium  that  failed  to  rally  after  the  consid- 
erable shock  that  we  produced. 

Dr.    Eisendrath's   work   on   pulmonary   embolus 
may  contribute  toward  the  explanation  of  this  death. 


34 


THE  BLADDER  IN  EARLY  TABES- 
REPORT  OF  CASE.* 

Bv  Wm.  S.  Ehrich,  M.  D.,  F.  A.  C.  S. 

While  we  are  all  familiar  with  the  vesical  con- 
ditions accompanying  tabes  dorsalis  in  the  later 
stages,  it  seems  from  the  scarcity  of  literature  that 
the  early  diagnosis  of  the  disease  by  means  of  cysto- 
scopic  findings  is  of  sufficient  rarity  to  make  the 
following  case  of  interest. 

The  only  cases  that  I  had  been  able  to  find  up 
to  the  time  when  this  diagnosis  was  made  were  two 
that  were  reported  by  Dr.  Irvin  S.  Koll  who  as- 
sures me  that  he,  too,  had  searched  literature  with- 
out finding  any  reference  to  this  condition. 

In  both  of  Dr.  KoU's  cases,  however,  there  were 
other  symptoms  recorded.  In  case  No.  1 ,  pain  is 
described  as  being  in  the  lumbar  region  radiating 
around  the  abdomen  and  down  to  the  bladder. 
Case  No.  2,  pain  which  was  typical  of  renal  colic. 
In  the  case  to  be  described  there  was  no  other 
symptoms  except  those  found  in  the  bladder. 

Case  No.  L  O.  H.  C.  Age  50  years;  travel- 
ing salesmem,  married,  weight  1 85  pounds,  height 
6  feet,  well  nourished. 

Complaint. — Inability  to  void  urine  without  con- 
siderable effort  and  time. 

Previous  History. — Infected  with  lues  23  years 
ago  and  with  gonorrhea  a  few  years  later.  Since 
the  latter  infection  he  has  always  had  more  or  less 
trouble  with  his  urine  but  it  has  become  much  worse 
in  the  last  six  months.  Nothing  else  of  interest  in 
his  former  life. 

Present  History. — The  patient  complains  of  an 
inability  to  completely  empty  the  bladder  without 
much  straining  and  taking  from  five  to  fifteen  min- 
utes to  void.  The  frequency  during  the  day  is 
practically  normal  but  he  arises  twice  to  three  times 
during  the  night  and  must  massage  the  abdomen  be- 
fore the  stream  of  urine  starts.  When  once  started 
the  stream  is  of  fair  size  and  is  ejected,  not  falling 
perpendicularly  from  the  penis. 

Physical   examination : 

Meatus. — Normal,  no  discharge. 

Urethra. — Normal,  dilated  with  Kollman  in- 
strument to  40  without  any  pain  nor  blood.  There 
was  little  resistance. 

Prostate. — Very  slightly  larger  than  normal,  not 
sensitive,  no  pus  in  secretion. 

Vesicles. — Normal. 

Testicles. — Normal,  no  sensitive  spots. 

Bladder. — Cystoscope  passed  without  any  pain 
or  even  inconvenience  and  there  was  no  anesthetic 
used.  The  cystoscopic  field  was  rather  striking. 
The  bladder  walls  showed  little  if  any  deepening 


*Read  before  the  American  Urological  Association,  North 
Central   Section,  Chicago,   November    12th,    1915. 


[Reprinted    from    THE   UROLOGIC   AND    CUTANE- 
OUS REVIEW,  February,  1916.] 


35 


of  color,  the  fundus  was  normal,  laterally  there 
were  fine  trabeculations,  the  prostate  was  not  ele- 
vated but  the  interureteric  ridge  was  prominent,  the 
ureteral  orifices  seemed  to  lack  the  normal  elasticity. 
Fully  dilating  the  bladder  made  no  change. 

Urine. — Residual  varied  but  at  times  reached 
6  ounces.  Chemical  and  microscopical  examina- 
tion normal. 

Blood.- — -Wassermann  reaction  negative,  could 
not  obtain  spinal   fluid. 

Reflexes  normal,  pupils  slightly  sluggish  but  not 

A-R. 

No  disturbance  of  coordination. 

No  Rhomberg. 

The  diagnosis  was  based  upon  ( 1  )  lack  of 
painful  sensation  during  instrumentation;  (2)  in- 
ability to  start  stream  which  was  of  fair  size  when 
started;  (3)  history  of  lues;  (4)  cystoscopic  find- 
ings. 


36 


A  NEW   FORM  OF  OPERATIVE  URE- 
THROSCOPE.* 

Bv  Ernest  G.  Mark.  M.  D.,  F.  A.  C.  S.,  Kansas 
City,    Missouri. 

In  the  Journal  of  the  American  Medical  As- 
sociation for  December  1 9,  1 903,  we  described 
our  first  type  of  air-inflation  operative  urethroscope 
which  was  later  presented  at  the  1 904  meeting 
of  the  American  Urological  Association.  This  in- 
strument was  the  outcome  of  studies  of  the  work 
of  KoUmann,  who  first  suggested  the  possibihties 
of  operative  work  through  the  urethroscope  and  of 
the  work  of  Antal,  of  Buda  Pesth,  of  Hurry  Fen- 
wick,  of  London,  and  of  Frank  Hewell,  of  New 
York,  who  were  the  pioneers  in  applying  the  air- 
inflation  principle  to  urethroscopy.  While  we  have 
been  keenly  aware  of  the  advantages  of  water  dis- 
tention in  urethroscopy  for  diagnostic  purposes,  we 
have  not  been  fully  convinced  of  any  superiority 
over  air-inflation  for  such  purpose  and  we  have  be- 
come more  and  more  firmly  convinced  of  the  over- 
whelming value  of  air-inflatation  in  intraurethral 
operative  procedures.  And  this  despite  our  report 
of  a  case  of  air-embolus  in  the  Journal  of  the 
American  Medical  Association  for  February  1  1 , 
1911,  occurring  under  air-inflation  operative  ure- 
throscopy. We  have  since  seen  similar  phenomena 
occur  fairly  frequently  but  attach  no  importance  to 
them. 

The  instrument  presented  by  us  in  1 903  and 
I  904  had  naturally  many  shortcomings,  but  these 
we  have  endeavored  to  rectify  in  the  instrument 
presented  here  which  has  been  made  for  us  by 
Wappler. 

The  accompanying  photograph  sufficiently  sug- 
gests the  use  of  the  various  operative  equipments. 
In  the  short  time  that  we  have  made  use  of  this  in- 
strument we  have  found  it  to  be  far  more  satisfac- 
tory than  any  other  with  which  we  are  acquainted. 
We  would  especially  call  attention  to  the  blade  of 
the  knife,  marked  Fig.  2,  No.  5,  for  stricture  work, 
which  we  believe  more  nearly  accords  with  the  type 
of  knife  used  in  urethrotomes  than  anything  which 
we  have  seen.  We  have  often  insisted  upon  the 
use  of  the  urethroscope  in  both  diagnosis  and  opera- 
tive treatment  of  certain  varieties  of  stricture.  In 
using  this  knife,  the  knife  is  advanced  beyond  the 
presenting  stricture,  placed  against  the  mucosa  and 
the  instrument  withdrawn  sharply,  care  being  taken 
that  the  air  inflation  is  stopped  before  the  incision 
is  made.  We  would  like  to  call  attention  to  the 
catheter-carrying  tube,  which  while  of  use  for  ca- 
theterizing  the  ureter  of  the  female  is  of  very  dis- 
tinct  advantage   in   high    frequency   destruction    of 


*Read  before  the  American  Urological  Association,  North 
Central   Section,   Chicago,   November    12th,    1915. 


[Reprinted    from    THE    UROLOGTC    AND    CUTANE- 
OUS REVIEW,  February,   1916.] 


37 


Fig.    I. 
Instrument     assembled     with     grasping     forceps     working  through    tube. 


Fig.    2. 

1,  Endoscopic  tube;  2,  light  earner  and  inside  tube;  3,  obturator;  4,  knife;  5,  stricture  knife 
with  universal  handle  attached;  6,  gold  cannula  with  syrmge;  7,  cannula  for  carrying  fulguralion  wire 
or    catheter;    8,    grasping    forceps;    9,    biting    forceps;     10,   window;     II,    galvano-caulery. 

38 


the  verumontanum  or  of  small  papillomata  in  the 
deep  urethra,  or  for  the  destruction  of  the  small 
bullae,  which  sometimes  present  at  the  vesical  neck. 

For  work  in  the  deep  urethra  the  instrument  is 
turned  upside  down  in  order  that  its  light  may  be 
thrown  more  distinctly  upon  the  floor  where  most 
of  the  pathological  conditions  occur.  The  cor- 
rugated forceps  are  for  the  purpose  of  removing 
foreign  bodies  from  the  urethra  and  bladder.  The 
biting  forceps  are  of  use  in  removing  bits  of  tissue, 
polypoid  growths,  etc. 

The  sharp  pointed  curved  knife  is  useful  in  split- 
ting up  cystic  follicles.  The  long  gold  cannula  is 
used  to  most  excellent  advantage  in  injecting  en- 
larged diseased  follicles.  We  no  longer  use  it  for 
the  purpose  of  catheterizing  and  injecting  the  ejacu- 
latory  ducts  since  the  operation  of  Belfield  and 
Herbst  has  been  devised.  The  small  electrolytic 
needle  is  of  more  advantage  in  the  destruction  of 
enlarged  diseased  crypts,  or  may  be  used  to  ad- 
vantage in  the  treatment  of  urethral  varix. 

The  instrument  as  a  whole  gives  the  best  opera- 
tive field  of  any  urethroscope  which  we  have  seen. 

In  1 904,  on  the  presentation  of  the  instrument 
before  the  American  Urological  Association,  there 
was  a  tendency  on  the  part  of  the  profession  to 
criticize  or  ignore  the  value  of  air-inflation  in  opera- 
tive urethroscopy.  It  is  indeed  gratifying  to  the 
author  to  note  that  a  great  many  of  the  urethro- 
scopes now  in  use  for  both  diagnostic  and  operative 
purposes,  have  adopted  the  air-inflation  principle. 
We  have  found  it  necessary  to  use  but  one  length 
of  tube  and  calibre  for  this  work  and  we  agree 
thoroughly  with  Young  that  a  meatus  which  does 
not  permit  of  the  introduction  of  number  26  F. 
instrument  is  too  small  for  accurate  or  satisfactory 
work  in  the  urethra.  In  all  such  cases  we  have  not 
hesitated  to  do  a  meatomy. 

626    Lathrop    Bldg. 


39 


ANATOMY  AND  PATHOLOGY  OF  THE 
SEMINAL  VESICLES.* 

By   E.   O.  Smith,   M.   D.,   Cincinnati,  Ohio, 

Professor    Cemio-Llrinary    Surgery,    Medical    Department, 
University    of    Cincinnati. 

The  seminal  vesicles  were  first  described  by  Fal- 
lopius,  1562,  and  may  therefore  be  designated  as 
the  male  Fallopian  tubes.  Further  analogy  between 
the  Fallopian  tubes  of  the  female  and  the  seminal 
vesicles  of  the  male  rests  on  the  fact  that  both  are 
not  only  frequently  involved  in  inflammatory  con- 
ditions, but  both  are  often  the  seat  of  gonorrheal 
infection. 

Allow  me  to  state  here  that  the  basis  of  this  dis- 
cussion was  a  prolonged  study  of  many  postmortem 
specimens  of  the  seminal  vesicles,  prostates  and  urin- 
ary bladders  obtained  from  the  Pathological  In- 
stitute of  the  Cincinnati  General  Hospital. 

The  seminal  vesicles  are  located  between  the 
urmary  bladder  and  the  rectum,  above  or  posterior 
to  the  prostate  gland,  and  external  to  the  vasa 
deferentia.  Fhe  duct  from  the  vas  joins  a  similar 
tube  from  the  vesicle  forming  the  ejaculatory  duct, 
which  with  a  corresponding  structure  from  the  op- 
posite side  passes  between  the  posterior  and  lateral 
prostatic  lobes  terminating  near  the  anterior  por- 
tion of  the  verumontanum  or  within  the  sinus  pocu- 
laris. 

The  lower  portion  of  the  vesicle  rests  upon  the 
posterior  border  of,  and  is  with  difficulty  separated 
from  the  prostate.  This  is  particularly  true  if  there 
has  been  chronic  inflammation  of  these  parts.  The 
general  direction  of  the  long  axis  of  the  vesicle  is 
upward  and  outward  from  the  posterior  border  of 
the  prostate  for  a  distance  varying  from  6  centi- 
meters to  22  centimeters.  The  angle  of  divergence 
varies  in  different  individuals,  and  may  vary  greatly 
in  the  same  individual,  this  depending  upon  a  col- 
lapsed or  dilated  condition  of  the  urinary  bladder. 
The  greater  the  bladder  distension,  the  farther  are 
the  upper  poles  from  the  mid-line. 

This  is  an  important  fad  to  bear  in  mind  when 
massaging  or  stripping  the  vesicles.  In  many  cases 
where  there  has  been  a  prolonged  obstruction  to  the 
outflow  of  urine  from  the  bladder,  the  long  axis  of 
the  vesicles  is  at  almost  right  angles  to  the  vertical 
or  mid-line  of  the  body. 

Except  in  very  short  vesicles  the  upper  pole  ex- 
tends to  and  in  most  specimens  overlap  the  ureter 
where  it  enters  the  outer  surface  of  the  bladder. 
The  vesicles,  except  the  lowest  portion,  are  exter- 
nal to  that  part  of  the  outer  wall  of  the  bladder 
which  corresponds  to  the  trigone,  and  are  held  in 


*Read  before  fhe  American  Urological  Association,  North 
Central   Section,  Chicago,   November    12th,    1915. 


[Reprinted    from    THE   UROLOGIC   AND   CUTANE- 
OUS REVIEW,  February,   1916.] 

40 


*3^^^ 


Fig.    1. 

Showing   relations   of   vesicles   to  prostate,  vasa  deferentiae,  bladder  and 
ureters. 


Vifostntc. 


Fig.  2. 

Long    axis    of    vesicles    forms    nearly     right    angles    with    long    axis    of 
body.      Upper,   outer   half   of   right   vesicle   contains   pus. 


41 


contact  with  this  portion  of  the  bladder.  This  ac- 
counts for  the  vesical  and  urinary  symptoms  that 
so  often  accompany  vesiculitis  and  perivesiculitis. 
It  might  be  added  that  the  aforementioned  symptoms 
have  frequently  been  treated  empirically  without 
regard  to  cause. 

Ihe  close  relation  of  the  upper  portion  of  the 
vesicle  to  the  ureter  explains  many  cases  of  nar- 
TOTved  ureters  due  to  impingement  on  the  ureter  of 
a  pathological  vesicle  and  its  consequent  thickening, 
plus  the  perivesicular  inflammatory  tissue.  All  who 
do  cystoscopic  work  have  had  the  experience  of 
being  unable  to  introduce  the  ureteral  catheter 
more  than  %  of  an  inch  to  1  inch,  yet  there  was 
urine  flowing  from  the  ureter.  There  can  be  no 
doubt  but  that  this  failure  is  often  due  to  a  narrow- 
ing of  the  lumen  of  the  ureter  and  a  fixation  of  it  by 
these  external  adhesions  from  the  vesicle.  As  a 
result  of  the  fixation  there  is  an  angulation  which 
the  ureteral  catheter  can  not  readily  pass.  It  is  a 
well  established  fact  that  a  normal  kidney  may  take 
bacteria  from  the  blood  stream  and  deposit  them 
in  the  urine  stream  without  damage  to  the  kidney 
itself.  It  has  further  been  demonstrated  that  even 
partial  obstruction  of  the  ureter  will  sufficiently 
lessen  the  normal  activity  and  resistance  of  the 
kidney  so  that  it  becomes  easy  prey  to  bacteria  in 
the  blood  stream. 

Following  these  facts  a  little  further  it  requires 
no  great  strain  on  the  imagination  to  see  how  chronic 
vesiculitis  and  perivesiculitis  can  be  a  predisposing 
factor  in  the  development  of  infections  of  the  kid- 
ney. 

Continuing  from  the  posterior  border  of  the  pros- 
tate is  a  fascial  membrane  which  extends  beyond 
the  vesicles.  This  can  easily  be  separated  from  the 
normal  vesicle,  but  with  much  difficulty  where  there 
has  been  perivesiculitis. 

Barnett  called  attention  to  the  importance  of 
getting  beneath  this  fascia  when  attempting  to  ex- 
pose the  vesicles,  either  for  drainage  or  removal. 
This  line  of  cleavage  once  found,  the  rectum  is  safe 
from  puncture.  Beneath  this  fascia  is  found  a 
much  thinner  fascial  layer  which  envelops  the  vesicle 
and  ampulla  of  the  vas  deferens.  Beneath  this  are 
other  bands  of  fascia  that  hold  in  place  the  various 
loops  and  saccules  of  the  vesicle.  The  normal 
vesicle  is  easily  detached  from  all  its  surroundings 
except  at  the  upper  pole,  where  the  blood  vessels 
enter  and  at  the  lowest  part  which  is  in  contact 
with  the  prostate.  In  doing  a  vesiculectomy  the 
vessels  at  the  upper  pole  should  be  ligated  before 
removal  of  the  vesicle  to  prevent  troublesome  or 
possible  fatal  hemorrhage.  The  loss  of  blood  from 
a  vesiculotomy  or  simple  drainage  operation  is  neg- 
ligible. 

In  about  one  of  every  ten  specimens  examined, 
the  peritoneum  extended  well  down  on  the  vesicles 
and  occasionally  to  the  posterior  border  of  the  pros- 
tate.     In   such   cases,   one   would   be   dangerously 

42 


near  the  peritoneal  cavity  when  operating  on  the 
vesicles. 

One  specimen  disclosed  no  distinct  vesicles,  but 
mere  rudiments  about  one-half  inch  in  length. 

Picker  in  a  paper  before  the  1  4th  International 
Medical  Congress  held  in  London,  1913,  grouped 
the  vesicles  according  to  their  anatomical  arrange- 
ment in  5  classes.      (  I  )    The  simple  straight  tubes ; 

(2)  thick  twisted  tubes  with  or  without  diverticula; 

(3)  thin  straight  or  twisted  tubes  with  or  without 
diverticula;  (4)  straight  or  twisted  mam  tube  with 
large  grape-like  diverticula;  (5)  short  main  tube 
with  large  irregular  ramified  branches.  This  seems 
to  be  an  unnecessary  multiplication  of  classes  as  the 
large  majority  of  the  specimens  I  examined  were 
of  the  continuous  tubular  type,  not  twisted  but 
folded  at  sharp  angles  upon  themselves  many  times. 
Most  of  the  other  varieties  were  simple  modifica- 
tions of  this  type.  There  were  a  few  pear-shaped 
vesicles,  whose  interior  had  the  appearance  of  mul- 
tiple saccules  communicatmg  with  a  common  chan- 
nel, or  vestibule,  but  not  a  distinct  tube  or  tubule. 

The  most  important  anatomical  feature  of  the 
vesicle  from  a  clinical  or  pathological  viewpoint  is 
the  multiple  sharp  angulations  of  the  tubule  in  a 
vast  majority  of  the  specimens.  There  can  be  no 
emptying  of  the  vesicles  except  by  some  sort  of  a 
peristaltic  wave  which  must  begin  at  the  blind  ex- 
tremity and  travel  along  the  tube  towards  its  out- 
let into  the  ejaculatory  duct.  I  am  inclined  to 
believe  that  much  of  the  benefit  that  patients  derive 
from  a  properly  executed  massage  of  the  vesicles 
is  due  to  a  stimulation  of  this  normal  peristaltic 
wave.  Very  much  on  the  same  principle  as  the  old 
time  massage  and  kneading  of  the  abdomen  to  en- 
courage intestinal  peristalsis,  before  the  days  of 
Lane's  kink,  Jackson's  membrane  and  Russian  oil. 
"A  properly  executed  massage,"  therefore,  is  a 
treatment  that  is  not  too  severe  and  does  not  pro- 
duce trauma. 

The  appearance  of  the  interior  of  a  normal  ves- 
icle is  that  of  fine  trabeculations,  suggesting  irreg- 
ularly arranged  spider  webs  or  tendrils.  When  this 
condition  does  not  present  and  the  tubules  or  sac- 
cules are  smooth  inside,  there  has  been  suppuration 
with  destruction  of  the  mucous  lining. 

The  vesicle  ivall  is  constructed  of  three  layers 
of  tissue.  The  outer  is  a  fibrous  layer,  beneath 
this  is  a  middle  layer  of  muscular  tissue,  which  pro- 
duces the  peristaltic  movements  that  empty  the  vesi- 
cle. The  interior  is  covered  with  a  mucous  mem- 
brane which  probably  has  some  secretory  function, 
not  fully  and  satisfactorily  explained.  The  ar- 
rangement of  the  tubules  gives  a  verp  extensive 
mucous  surface  ivith  the  tvorst  natural  drainage. 
This,  partially  at  least,  accounts  for  the  fact  that 
about  50  per  cent,  of  the  post-mortem  specimens 
examined  were,  in  some  way  pathological.  The 
farther  up  the  tubule,  near  the  blind  end,  the  more 
difficult  is  the  drainage,   hence,   we  would   expect 

43 


0>^ 


dl-l 


^■^"^  -w 


i 

i!52« — .; — TnoiXATt 


F.g  3. 

Peritoneum    extends    to    prostate    covering  vesicles  and  vasa.     Has  been 
removed   from   right   side. 


"PrtoSTKTK 


Fig.  4. 


Vesicles  seat  of   suppuration.     Left  vesicle   turned  down  showing  tortu- 
ous and  angulated  vas. 


44 


to  find  most  of  the  pathological  conditions  in  the 
upper  portion  of  the  vesicles,  where  they  were. 

Our  findings  in  these  specimens  demonstrate  that 
a  simple  single  incision,  especially  in  the  lower  part 
of  a  vesicle  containing  pus,  fvill  not,  can  not,  estab- 
lish satisfactory  surgical  drainage.  To  drain  prop- 
perly,  multiple  incisions  are  required,  particularly 
high  up  on  the  vesicle.  Judging  from  the  specimens 
alone  one  would  be  led  to  the  conclusion  that  noth- 
ing short  of  a  vesiculectomy  could  be  effective,  yet 
we  know  from  practical  experience  that  thorough 
vesiculotomy  is  followed  by  the  most  satisfactory 
results  in  properly  selected  cases. 

While  these  structures  were  discovered  by  Fal- 
lopius  in  the  1  6th  century,  and  recognized  as  the 
seat  of  inflammation  by  Morgagni  in  the  1  8th  cen- 
tury (1745),  it  remained  for  Fuller  and  Belfield, 
about  the  beginning  of  the  20th  century,  to  bring  to 
our  attention  the  importance  of  these  hollow  organs 
as  the  hiding  place  for  numerous  bacteria — prin- 
cipally Neisser's  diplococcus,  and  its  associates,  the 
staphylococcus,  the  streptococcus  and  the  colon 
bacillus.  It  was  they  who  demonstrated  the  rela- 
tion between  chronic  seminal  vesiculitis,  chronic  re- 
current urethral  discharge,  and  certain  cases  of 
arthritis.  Invasion  of  the  vesicles  by  bacteria  from 
the  posterior  urethra  is  certainly  a  simple  matter, 
there  being  required  only  a  short  trip  through  the 
ejaculatory  duct,  a  distance  of  little  more  than  one 
inch.  Theoretically,  at  least,  one  would  suppose 
from  the  very  nearness  of  the  vesicles  to  the  pos- 
terior urethra,  as  compared  to  the  epididymis,  that 
the  vesicles  would  be  more  frequently  involved  in 
secondary  infection  than  is  the  epididymis.  Who 
can  say  they  are  not?  It  may  be  that  the  fre- 
quency of  vesicular  infections  varies  in  direct  propor- 
tion to  the  degree  of  diligence  in  examining  these 
structures. 

Lewin  and  Baum  examined  1 ,000  cases  of  gon- 
orrhea, and  found  the  posterior  urethra  involved  in 
65  per  cent.,  and  the  seminal  vesicles  in  35  per  cent. 
While  there  are  no  statistics  at  hand  to  prove  the 
assumption,  it  seems  reasonable  that  the  vesicles 
could  easily  be  infected  from  every  case  of  chronic 
posterior  urethritis,  and  in  many  cases  of  acute 
posterior  urethritis.  If  any  surprise  is  to  be  ex- 
pressed, it  is  that  they  escape  in  any  case  of  pos- 
terior urethritis. 

When  looking  about  for  ''focal  infections,''  the 
vesicles  must  not  be  overlooked.  Before  having  a 
few  hundred  dollars  worth  of  bridgework  removed 
from  a  patient's  mouth  for  arthritis,  it  would  do  no 
harm  to  investigate  the  vesicles.  The  fact  that  the 
patient  states  that  he  has  never  had  gonorrhea 
should  not  deter  one  from  examining  the  vesicles. 
He  may  be  mistaken  or  may  have  forgotten,  be- 
sides a  previous  gonorrheal  infection  is  not  ab- 
solutely necessary. 

Vesiculitis  may  present  in  men  who  live  under 
a  high  nervous  tension,  who  indulge  in  sexual  ex- 

45 


y^iiuc 


^i>-<*''"         woe  \\ 


Uif«*'«^ 


Fig.  5. 

Vesicles  filled  with  pus,  divided  in  half,  posterior  walls  turned  out  ex- 
posing  saccules. 


^y^:-**(^-^i^ 


Vesicj.£" 


%~r/\TE. 


F.g.  6. 

Dense  tissue  about  vesicles,  vasa  and  prostate,  result  of  chronic  inflam- 
mation.     Left  vesicle  has  been   dissected    from    its    bed    of    adhesions. 


46 


cesses  both  normal  and  abnormal,  and  who  are  in- 
temperate in  the  use  of  tobacco  and  alcohol.  Horse- 
back riding,  bicycle  and  motorcycle  riding  are  con- 
tributing factors  toward  the  development  of  ves- 
icle trouble. 

Dr.  Robert  T.  Morris  has  given  out  for  careful 
consideration  and  investigation  the  suggestion  that 
possibly  there  is  some  relation  between  "focal  in- 
fection" and  malignancy,  even  though  the  malig- 
nancy be  in  some  part  of  the  body  far  removed 
from  the  focus  of  infection.  While,  at  first  thought, 
this  may  seem  far-fetched,  yet  it  is  a  study  in  bio- 
chemistry, which  has  much  more  to  commend  it 
than  the  suggestion  a  few  years  ago  that  goitre  and 
mammary  malignancy  were  produced  by  intestinal 
stasis. 

Tuberculosis  of  the  vesicles  is  practically  always 
secondary  to  tuberculosis  elsewhere  in  the  genital 
tract.  Contrary  to  much  of  the  information  we 
formerly  had,  it  was  found  that  vesicles  which  felt 
nodular  when  examined  digitally  per  rectum  are  not 
necessarily  the  seat  of  tuberculosis.  What  was 
diagnosed  as  tuberculous  nodules  from  palpation  in 
some  specimens  proved  to  be  thickened  and  scleros- 
ed areas  at  the  sharp  angles  of  the  tubules.  In  one 
specimen  a  small  single  nodule,  about  the  size  of 
a  navy  bean  was  felt  in  the  right  seminal  vesicle. 
When  this  was  dissected  out  it  was  a  very  firm 
and  completely  capsulated  cyst  which  contained  a 
clear   gelatinous   material. 

The  only  cases  of  malignancy  found  were  sec- 
ondary to  malignancy  in  the  wall  of  the  urinary 
bladder.  There  is  no  logical  reason  why  the  vesi- 
cles should  not  be  involved  in  primary  malignancy, 
and  no  doubt  they  are,  yet  none  were  found  among 
the  specimens  forming  the  basis  of  this  study. 

No  calculi  were  found  in  the  vesicles  among  our 
specimens.  They  certainly  are  not  very  common. 
Dr.  Eugene  Fuller  informed  me  in  a  personal  com- 
munication that  in  the  more  than  seven  hundred 
vesiculotomies  that  he  has  performed  he  found  cal- 
culi in  only  seven  cases,  and  but  once  m  both  ves- 
icles of  the  same  patient. 

There  is  a  case  reported  by  James  and  Shumain 
where  a  seminal  vesicle  calculus  gave  rise  to  the 
same  symptoms  as  those  typical  of  renal  colic,  and 
it  was  not  discovered  until  after  a  futile  surgical 
search  was  made  for  a  stone  in  the  ureter.  This 
is  an  exceptional  case,  and  an  error  that  amy  one 
might  have  made.  However,  with  such  a  case 
report  before  us,  we  should  profit  by  their  experi- 
ence, and  ever  keep  this  possibility  in  mind  when 
studying  "renal  colic." 

The  points  in  the  study  of  the  anatomy  and 
pathology  of  the  seminal  vesicles  that  seem  worthy 
of  sF>ecial  mention  are: 

( 1  )  The  wide  variations  in  size  and  positions 
of  the  vesicles ; 

(2)  Frequency  of  vesiculitis,  both  suppurative 
and  inflammatory  (focal  infections) 

47 


(3)  The  close  relation  of  the  vesicles  to  the 
ureters  and  in  some  cases  to  the  peritoneum ; 

(4)  The  futility  of  severe  massage  treatments; 

(5)  The  importance  of  multiple  incisions  par- 
ticularly in  the  distal  portions,  when  surgical  drain- 
age is  being  done;  and 

(6)  Palpable  vesicle  nodules  are  not  always 
tuberculous. 

BIBLIOGRAPHY. 

Barnell,  C.  E.:  Pathology  of  the  Seminal  Vesicles  and 
Prostate,  with  Suggestions  of  the  Necessity  for  Surgical 
Treatment.     (/.  Indiana  M.  Assn.,  1909,  V.  2.  pp.  320-22.) 

Barney,  J.  D.:  Observations  on  the  Seminal  Vesicles. 
(Tr.  Am.  Ass.  Cenito-Urin.  Surg.,  1914,  V.  9.  pp.  72-91.) 

Barney,  J.  D.:  Recent  Studies  in  the  Pathology  of 
Seminal  Vesicles.  (Bost.  M.  and  S.  /.,  1914,  V.  171, 
pp.   59-62.) 

Belfield,  W.  T.:  Pus  Tubes  in  the  Male,  Surgical  and 
Vaccine  Treatment.  {Jour.  A.  M.  A.,  1909,  Vol.  53, 
pp.    2141-43.) 

Ceelen,  W. :  Ein  Fibromyom  der  Samenblase.  (^Vir- 
choiv's  Arch.  f.  path.  Anal.,   1912,  V.  207,  pp.  200-206.) 

Felix,  W.:  Zur  Anatomic  des  Ductus  Ejaculatorius,  der 
Ampulla  Ductus  Deferentis  und  der  Vasicula  seminalis  des 
Erwachsenen  Mannes.      (^Anal.,  Hefte.   1901,  V.   17,  pp.   1- 

50.) 

Fuller,  Eugene:    Seminal  Vesiculotomy.    {Jour.  A.  M.  A., 

Vol.  59,  pp.   1959-62.) 

Hyman,  A.  and  Saunders,  A.  S. :  Chronic  Seminal  Vesi- 
culitis; A  Clinical  Resume  with  Special  Reference  to  the 
Urethroscopic    Findings  in   the   Posterior   Urethra.      (A^.    Y. 

M.  /.,  1913,  V.  97,  pp.  652-54.) 

James  and  Shuman:  Seminal  Vesical  Calculus  Simulat- 
ing Nephrolithiasis.     {Sur§.,  Cyn.  and  Obsiei.,  XVI,  1913.) 

Junkerman,  C.  F.:  Hematuria  and  the  Pathology  of 
Chronic  Seminal  Vesiculitis  and  AmpuUitis  Under  Which 
Latter  Disorder  We  Get  Bloody  Semen.  (Med.  Cenlury, 
1911,  V.    18,  pp.    113-15.) 

Lewin,  A.  and  Bohm,  G.:  Zur  Pathologic  der  Sperma- 
tocystitis  Gonorrhoica.  {Zlschr.  f.  Urol.,  1909,  V.  3,  pp. 
43-64.) 

Nussbaum,  M.:  Ueber  den  Bau  und  die  Tatigkeit  der 
Driisen.  VI.  Der  Bau  und  die  Cyclischen  Verander- 
ungen    der    Samenblasen    von    Ranafusca.      {Arch.    f.    mi'^r. 

Anal.,  1912,  V.  80,  2  Abt.,  pp.  1-59.) 

Oberndorfer,  S.:  Beitrage  zur  Anatomic  und  Pathologic 
der   Samenblasen.      {Beilr.  z.  path.  Anal.  u.  z.  allg.  Path., 

1902,  V.  31,  pp.  325-46.) 

Petersen,  O.  V.  C.  E.:  Beitrage  zur  Mikroskopischen 
Anatomic  der  Vesicula  seminalis  des  Menschen  und  Einiger 
Saugeticrc.      {Anal.,    Hefte.    1907,    V.    34,   pp.    237-62.) 

Quinby,  W.  C:  The  Anatomy  and  Physiology  of  the 
Seminal  Vesicles  with  Regard  to  the  Treatment  of  Their 
Lesions.  {Boston.  M.  and  S.  J.,  1914,  V.  170,  p.  58. 
Discussion,    pp.    68-71.) 

Thomas,  B.  A.  and  Pancoast,  H.  K.:  Observations  on 
the  Pathology,  Diagnosis  and  Treatment  of  Seminal  Vesi- 
culitis.    {Ann.  Surg.,  1914.  V.  60,  pp.  313-18.) 

Voelckcr    (Heidelberg):      Die    Samenblasen.      1912. 

Weisz,  F.:  Zur  Aeliologie  und  Pathologic  der  Samcn- 
blasenerkrankungem.  {Wien.  med.  Presse.,  1904,  V.  45, 
p.   1581.) 


48 


OPERATIONS  BY  LOCAL  ANESTHESIA 
ON      THE      EXTERNAL     GENI- 
TALIA AND  PROSTATE.* 

By  a.  C.  Stokes,  M.  D. 

About  ten  years  ago  we  began  doing  operations 
by  local  infiltration  anesthesia.  This  paper  is  meant 
to  cover  some  of  our  practical  impressions  gleaned 
from  experience  in  the  above  operations. 

First.  To  do  these  operations  successfully  with- 
out pain  to  the  patient,  the  operator  must  have  thor- 
ough command  of  himself  and  be  in  a  position  to 
meet  every  emergency  of  the  operation  without  ir- 
ritation or  disturbance  of  the  equilibrium  of  the 
operating  room.  The  progress  of  the  operation 
must  be  without  a  break  in  technique. 

Second:  The  cutting  instruments  used  must 
be  very  sharp.  Little  or  no  pain  is  produced 
by  cutting  but  patients  cannot  tolerate  pulling 
or  dragging  on  the  tissues.  Artery  clamps  must 
not  be  pulled,  retractors  must  be  handled  with  the 
utmost  care  and  dissections  must  not  be  made  until 
we  are  certain  that  the  field  of  dissection  is  thor- 
oughly infiltrated,  and. then  with  cutting  instruments 
only. 

Third:  One  must  assure  the  patient  that  any 
time  that  he  feels  pain  or  is  hurt  that  you  will  stop 
at  his  request.  A  tactful  nurse  or  house  officer 
must  sit  at  the  head  of  the  patient  and  engage  him 
in  conversation  as  much  as  possible  during  the  en- 
tire time  of  the  operation.  The  patient  must  be 
assured  that  he  will  not  be  harmed  and  that  no 
pain  will  supervene.  The  eyes  should  be  covered 
because  to  some  people  the  sight  of  blood  produces 
a  bad  temporary  reaction.  Our  records  show  that 
we  have  done  during  the  last  ten  years  the  follow- 
ing operations  by  local  anesthesia:  Inguinal  hernia, 
34  cases ;  hydrocele,  1  9  cases ;  varicocele,  32  cases ; 
prostatectomy,  3  cases ;  amputation  of  the  penis  and 
removal  of  the  inguinal  glands,  1  case;  hemor- 
rhoids, 5  cases;  suprapubic  cystotomy,  for  different 
reasons,  1  2  times. 

It  is  not  my  purpose  to  discuss  the  question  of 
general  analgesia  by  infiltrating  large  trunks  of 
plexes  of  nerves  or  by  introducing  anesthetic  sub- 
stances into  the  spinal  cord.  Our  experiences  to- 
gether with  those  of  the  reports,  have  shown 
that  these  methods  are  not  only  impractical  but 
contain  elements  of  danger  to  which  we  do  not 
care  to  subject  our  patients.  We  are  convinced 
that  the  only  local  anesthetic  worth  considering  is 
an  anesthetic  which  infiltrates  or  blocks  the  nerves 
in  the  immediate  area  of  operation.  Infiltration 
of  the  sacral  plexus  or  brachial  plexus  or  any  other 


*Read  before  the  American  Urological  Association,  North 
Central  Section,  Chicago,   November   12th,    1915. 


[Reprinted    from   THE   UROLOGIC   AND    CUTANE- 
OUS REVIEW,   February.   1916.1 


49 


nerve  trunks  distant  from  the  field  of  operation  is 
not  practical. 

To  infiltrate  small  nerves  in  the  region  of 
operations  like  those  done  on  the  external  geni- 
talia, it  is  necessary  to  infiltrate  the  area  around 
the  operative  field,  because  the  nerves  are  not  quite 
definite  in  their  course  or  in  their  distribution,  euid  to 
say  that  the  genital  branch  of  the  genito-crural 
supplies  the  region  of  the  scrotum  does  not  describe 
its  course  and  we  note  further  that  the  description 
of  the  course  of  these  nerves  varies  in  different 
anatomies  and  one  must  infiltrate  the  entire  area 
w^here  these  nerves  may  possibly  run.  It  becomes 
necessary  to  point  out  in  each  operation  the  neces- 
sary areas  to  infiltrate. 

During  these  operations  we  have  used  various 
solutions  starting  with  Schleich's  solution,  cocaine, 
morphine  and  cocaine,  eucaine,  quinine  hydro- 
chloride, alypin,  stovaine  and  novocaine.  We 
have  discontinued  the  use  of  cocaine  and  its 
immediate  derivatives  and  also  morphine  and  sto- 
vaine, leaving  only  alypin,  quinine  hydrochloride 
and  novocaine.  These  three  drugs  have  possi- 
bilities in  local  infiltration.  Novocaine  is  by  far  the 
most  commonly  used.  In  hernia  cases  six  were  done 
with  cocaine,  three  with  Schleich's  solution,  two 
with  eucaine,  leaving  twenty-three  that  have  been 
done  with  novocaine  in  some  concentration  or  other. 
No  hernia  has  been  done  with  quinine  infiltration. 

In  hydrocele  all  but  four  cases  have  been  done 
under  novocaine.  Of  these  four,  two  were  done 
with  Schleich's  solution  and  two  with  quinine.  Of 
thirty-two  variocele  cases,  three  were  done  with 
cocaine,  five  with  quinine  and  the  remaining  with 
novocaine. 

Of  the  suprapubic  cystotomies  two  were  done 
with  cocaine  and  the  rest  with  novocaine.  In  hemor- 
rhoids no  drug  except  novocaine  has  been  employed. 
In  prostatectomies  our  aim  has  been  to  combine 
several  anesthetics  as  will  be  brought  out  later  in 
the  paper. 

The  next  point  of  interest  is  the  reason 
why  we  have  chosen  one  anesthetic  or  another. 
Alypin  is  quite  toxic  and  in  doses  of  larger  quanti- 
ties than  a  gram  we  are  fearful  of  its  results. 
It  was  used  to  anesthetize  mucous  membranes 
either  as  a  solution  dropped  directly  on  the 
mucous  membrane  as  a  tablet  in  the  posterior 
urethra  or  as  a  solution  in  the  bladder  or  rec- 
tum. As  an  infiltrating  agent  to  be  used  subcuta- 
neously  or  intercutaneously  it  is  not  to  be  considered. 
Quinine  is  recommended  by  Hertzler  as  con- 
taining anesthetic  properties.  It  is  non-toxic  and 
can  be  used  in  any  quantities  without  any  toxic 
results  whatever.  While  Hertzler  claims  that  qui- 
nine has  the  same  therapeutic  results  as  novocaine 
our  results  have  seemed  to  prove  that  especially  in 
regions  where  the  skin  is  very  thin,  healing  is  not 
as  prompt  and  sloughing  occasionally  takes  place 
following    its    use.      The    anesthesia    produced    by 

50 


quinine  lasts  as  long  as  that  produced  by  novocaine. 
Novocaine  has  a  toxic  element  that  must  always 
be  remembered.  It  is  not  safe  to  inject  over  four 
or  five  grains  of  novocaiiie  at  one  time  for  any 
operation  although  the  recorded  toxic  dose  is  seven 
grains. 

Despite  opposition  to  local  anesthesia  it  is  slowly 
advancing  in  the  field  of  surgery  and  the  above 
operations,  with  the  exception  possibly  of  some  cases 
of  hernia  and  prostatectomy  should  always  be  done 
with  local  anesthesia  rather  than  general.  Mor- 
phine was  used  hypodermically,  injecting  a  quarter 
of  a  grain  an  hour  before  each  operation.  A  one 
hundredth  of  a  grain  of  scopolamine  was  added. 
For  a  few  operations  morphine  and  scopolamine 
three-fourths  of  an  hour  before  each  operation  was 
used.  In  a  certain  number  of  cases  more  or  less 
vomiting  was  seen  and  two  patients  suffered  respira- 
tory troubles.  In  about  ten  per  cent,  of  our  cases 
temporary  shock  almost  to  the  point  of  fainting  dur- 
ing the  operation  was  noted.  In  about  six  per 
cent,  of  our  cases  the  patient  vomited  three  or 
four  times  after  the  operation.  Possibly  the 
vomiting  and  the  fainting  and  the  sick  feeling  were 
due  to  morphine.  It,  therefore,  became  our  desire 
to  do  these  operations  without  the  use  of  any 
general  narcotic.  Since  that  time  have  been 
done  eighteen  hernias,  nineteen  hydrocele  opera- 
tions, twenty-two  operations  for  varicocele,  and  two 
prostatectomies  without  a  hypodermic  injection  of 
any  drug  that  produced  a  general  narcosis.  Since 
this  change  our  patients  have  rarely  vomited.  Sick 
feelings,  such  as  dizziness,  have  followed  only 
three  cases  of  hernia,  three  cases  of  hydrocele, 
no  case  of  varicocele,  and  these  were  casfes  in  which 
large  quantities  of  novocaine  were  used. 

In  hernia  the  skin  was  infiltrated  by  the  methods 
of  wheals  and  the  line  of  incision  by  intro- 
ducing the  solution  intracutaneously.  The  in- 
ternal solution  is  introduced  by  a  small  hypodermic 
needle  after  which  the  desired  quantity  of  solution 
may  be  introduced  subcutaneously  and  into  the  fascia 
of  the  external  oblique.  The  incision  is  then  made 
down  to  the  cord,  and  now  our  chief  trouble  besjins 
in  anesthetizing  the  fascia  of  the  cremasteric  and 
peritoneum  of  the  sack.  These  anatomical  struc- 
tures are  supplied  by  the  genital  branch  of  the 
genito-crural  and  that  it  usually  runs  posterior  to 
the  cord.  Our  troubles  are  then  to  infiltrate  the 
cord  and  sack  so  that  we  can  separate  one  from 
the  other.  A  circular  infiltration  of  the  external  ring 
as  far  under  the  cord  as  possible  will  answer  all  pur- 
poses necessary.  This  infiltration  should  be  made  as 
soon  as  the  cord  is  reached  and  then  time  for  the 
anesthetic  to  take  effect  should  be  allowed,  which 
time  can  be  used  by  the  operator  in  dissecting  back 
the  fascia  of  the  external  oblique  branch.  At  the 
end  of  that  time  the  cord  will  be  anesthetized.  By 
gentle  dissection  with  a  blunt  instrument  the  cord 
and   sack  can  be  raised   out  of   its  bed.      If  now 

.51 


there  are  any  sensitive  points  the  cords  can  be  fur- 
ther infiltrated  and  the  cord  separated  from  its  fas- 
cia after  the  sack  is  separated  from  its  fascia.  It 
is  well  to  make  a  circular  infiltration  on  the  base 
of  the  sack  before  an  attempt  to  tie  off  is  made. 
The  tie  having  been  made  and  the  sack  cut  off  the 
operation  for  hernia  is  practically  finished.  No 
trouble  has  been  experienced  in  closing  the  hernia 
wound. 

Operations  for  varicocele  are  so  simple  that 
they  should  be  done  with  local  anesthesia.  In- 
filtrating the  skin  and  the  top  fascia  and  the  fascia 
about  the  veins  is  a  perfectly  simple  proposition, 
and  raising  up  the  veins  and  cutting  and  tying 
them  or  disposing  of  them  in  any  way  you  see  fit 
has  never  in  our  experience  met  with  any  danger 
or  difficulty  whatever. 

Hydrocele  is  an  operation  that  can  be  done  under 
local  anesthesia.  Our  hydrocele  records  show  that 
8  per  cent,  of  them  suffer  from  some  pain  in  the 
dissection  of  the  tunica  from  the  cremasteric 
fascia.  No  attempt  should  be  made  to  anesthetize 
the  cremasteric  fascia  from  the  outside  before  the 
incision  is  made  through  the  scrotum  into  the  sack, 
and  very  careful  infiltration  must  then  be  made 
around  the  entire  circumference  of  the  neck  of  the 
sack  clear  at  the  top  of  the  hydrocele.  After  this 
infiltration  is  complete  and  thorough  the  removal 
of  the  tunica  is  made  with  absolutely  no  pain 
and  can  be  done  with  a  pair  of  sharp  scissors  as 
quickly  as  it  can  be  done  under  general  anesthesia. 

Amputation  of  the  penis  offers  no  difficulties. 
The  nerves  all  pass  out  on  the  dorsal  side  and 
can  be  infiltrated  at  the  base  and  the  entire  organ 
removed  with  absolutely  no  pain.  Removal  of  the 
glands  of  the  groin,  however,  is  better  done  with 
general  anesthesia.  Local  is  used  when  absolutely 
necessary  and  when  general  is  contraindicated. 

We  have  not  removed  a  kidney  but  by  proper 
para-vertebral  infiltration  this  operation  could  be 
done  easily.  Ten  cases  have  been  collected  from 
literature  in  which  a  kidney  has  been  removed  by 
local  anesthesia. 

The  chief  excuse  for  writing  this  paper  at 
this  time  is  the  possibility  of  developing  a  tech- 
nique by  which  we  can  do  prostatectomies  under 
local  anesthesia.  Three  cases  have  arisen  in 
which  a  general  anesthetic  was  contraindicated. 
Following  the  reports  of  Allen,  Legueu  and 
others  we  have  tried  to  develop  a  technique  for 
the  removal  of  the  prostate  suprapubically  by  means 
of  local  anesthesia  and  not  by  sacral  anesthesia  or 
the  infiltration  of  large  nerves  but  by  infiltrating 
the  area  of  operation  as  we  proceed.  Our  tech- 
nique at  present  has  resolved  itself  into  the  follow- 
ing: 

No  morphine  at  all  is  given  hypodermically  or 
any  other  narcotic.  One-half  hour  before  the 
operation  the  rectum  is  washed  out  clean  and  two 
ounces  of  a  five  per  cent,   alypin   solution   are  in- 

52 


troduced.  The  posterior  urethra  is  anesthetized 
by  depositing  a  tablet  of  alypin  there.  The  bladder 
is  filled  with  a  one-quarter  of  one  per  cent,  of  solu- 
tion of  alypin.  The  suprapubic  region  is  now  in- 
filtrated with  novocaine  and  an  incision  is  made 
down  through  the  abdominal  wall,  into  the  space 
of  Retzius  as  usual ;  the  anterior  surface  of  the 
bladder  is  again  infiltrated  with  novocaine  and  the 
bladder  is  opened  by  a  large  incision  extending 
down  to  the  symphysis  and  almost  to  the  prostate. 
By  careful  retraction  the  prostate  may  now  be 
brought  into  view.  The  hardest  problem  now  pre- 
sents itself,  anesthetizing  the  prostate.  A  ten  per 
cent,  solution  of  hydrochloride  of  quinine  and  urea. 
By  the  use  of  a  long  needle  we  aim  to  infiltrate  the 
region  between  the  true  capsule  of  the  prostate  and 
the  prostate  proper  with  large  quantities  of  quinine, 
knowing  that  quinine  is  a  circulatory  stimulant  and 
will  to  a  certain  extent  react  against  the  alypin 
and  novocaine.  When  this  is  done  a  small  in- 
cision is  made  with  a  sharp  knife  through  the  mu- 
cous membrane  to  the  prostate  in  the  region  of  the 
posterior  urethra  aind  an  attempt  is  made  to  shell 
out  the  prostate  as  usual.  A  finger  is  introduced 
into  the  rectum  and  the  prostate  is  pushed  up  into 
the  region  of  the  bladder  and  we  proceed  to  shell 
it  out.  This  must  oftentimes  be  done  very  slowly 
and  gently.  If  the  incision  can  be  made 
around  the  prostate  and  there  are  no  adhesion 
of  the  prostate  to  the  capsule  it  will  slip  out  with- 
out pain.  Some  pain  has  been  experienced 
at  this  point.  In  our  first  case,  a  prostate 
done  by  this  method,  morphine  was  used  and 
the  patient  promptly  died  in  twenty-four  hours. 
Braun  in  his  most  excellent  work  on  this 
subject  states  that  morphine  is  absolutely 
contra-indicated  in  all  prostatectomies  done  under 
local  anesthesia.  He  states  very  tersely,  "It  is 
paradoxical  to  attempt  to  drive  out  the  devil  by 
the  use  of  Beelzebub."  Our  other  two  cases  re- 
covered uneventfully.  So  indefinite  seems  to  be 
the  knowledge  of  our  nerve  supply  to  the  prostate 
that  we  are  not  quite  clear  that  our  procedure  is 
entirely  rational.  The  use  of  quinine  in  the  infil- 
tration of  the  prostate  is  a  correct  procedure. 
Whether  we  should  endeavor  to  infiltrate  the  en- 
tire prostate  or  only  between  the  capsule  of  the 
prostate  is  not  clear. 

We  have  had  no  experience  with  perineal  pros- 
tatectomy under  local  anesthesia. 


TRANSACTIONS 

Chicago  Urological  Society, 
MEETING.  OCTOBER  21,   1915. 

The  Chicago  Urological  Society  met  at  the  Hotel 
La  Salle  October  21,  1915,  with  the  President, 
Dr.  Herman  L.  Kretschmer  in  the  chair. 

Dr.  G.  Kolischer  read  a  paper  on  "Diathermia 
in  Malignant  Tumors  of  the  Bladder." 

Discussion. 

Dr.  D.  N.  Eisendralh. — I  have  not  had  ex- 
perience with  radiotherapy  or  mesothorium  in  blad- 
der tumors,  except  to  see  the  patients.  I  saw  the 
patient  Dr.  Kolischer  speaks  of,  and  certainly  so 
far  as  his  condition  is  concerned,  he  is  in  most  ex- 
cellent shape.  I  cam  heartily  endorse  what  Dr. 
Kolischer  said  of  the  action  of  the  X-ray  on  super- 
ficial cancers,  such  as  cancers  of  the  tongue,  or 
in  preventing  the  recurrence  of  carcinoma  of  the 
breast.  The  results  are  positively  marvelous  where 
we  formerly  resorted  to  the  knife  m  carcinoma  of 
the  tongue;  cases  in  which  the  whole  floor  of  the 
mouth  was  exulcerated,  with  fetor,  and  the  tongue 
fixed  to  the  floor  of  the  mouth,  the  disappearance 
after  a  series  of  X-ray  treatments  is  simply  unbe- 
lievable unless  you  have  seen  these  cases.  So  far 
I  can  endorse  the  general  principles  which  Dr. 
Kolischer  has  stated.  There  was  no  doubt  about 
the  malignancy  of  the  tumors,  and  then  watching 
them  heal  over  and  soften  up,  and  the  whole  mu- 
cous membrane  in  the  bladder  as  he  has  described, 
cuid  the  tumor  mass  being  replaced  by  smooth  mu- 
cous membrane — I  did  not  believe  I  would  live 
to  see  the  day. 

Dr.  J.  Eisenstaedt. — I  have  seen  Dr.  Kolischer's 
work  for  the  past  four  or  five  months,  and  it  is  en- 
couraging in  certain  cases.  The  ceises  thus  far 
have  to  be  selected  about  which  we  can  use  the 
term  encouraging.  Dr.  Kolischer  has  given  me 
credit  for  making  precipitins.  I  was  prompted  to 
do  it  by  Dr.  J.  Walter  Vaughan  of  Ann  Arbor. 
He  took  me  into  the  Harper  Hospital  in  Detroit 
and  showed  me  a  womaji  with  carcinoma  of  the 
rectum  which  had  grown  out  over  the  gluteal  area, 
and  almost  unbelievably,  this  woman  was  sitting 
on  that  apparently  without  pain.  The  pain  was 
controlled  by  the  use  of  precipitins.  Dr.  Vaughan 
does  not  use  radiotherapy — either  radium  or  meso- 
thorium or  the  X-ray — in  connection  with  the  preci- 
pitin injections.  However,  these  injections .  in  his 
hands  are  seemingly  very  encouraging  for  certain 
cases.  A  report  of  his  work  came  out  in  one  of  the 
popular  magazines  which  had  a  bit  too  much  glamor 
to  it,  but  this  much  I  believe  can  be  said:  Their 
manufacture  is  simple.  An  untrained  laboratory 
man,  such  as  I  am,  can  make  them  and  make  them 


rReprinterl    from    THE   UROLOGIC    AND    CUTANE- 
OUS REVIEW,  February,   1916.] 

54 


accurately,  and  I  believe  in  these  absolutely  hope-' 
less  cases  if  we  are  only  able  to  minimize  the  pain, 
and  in  cases  which  do  present  hope  either  by  the 
knife  or  X-ray  treatment,  we  can  possibly  by  the 
use  of  precipitins  prevent  the  formation  of  metas- 
tzises,  and  then  we  would  have  something  which 
would  prove  a  very  valuable  adjunct. 

Adjourned. 


55 


PHYLACOGEN  IN  UROLOGICAL 
PRACTICE.* 

Bv   Frederick   W.   Robbins,   M.  D.,   F.  A.  C.  S.. 
Detroit,    Michigan. 

It  may  seem  unnecessary  at  this  lime  to  refer  to 
a  method  of  medication  that  has  been  before  the 
medical  profession  for  nearly  three  years.  If  of 
decided  value,  it  should  have  received  general 
recognition ;  if  not,  oblivion  vv^ere  its  proper  burying 
ground.  That  it  has  not  been  generally  accepted 
by  those  most  competent  to  judge,  is  evident  from 
the  small  number  of  cases  treated  with  phylacogen, 
by  Detroit  urologists;  that  it  has  not  yet  passed  into 
oblivion,  the  great  volume  of  sales  bears  witness. 

At  the  outset,  let  me  confess  to  having  been 
prejudiced  against  phylacogen,  not  because  of  any 
theoretical  objection,  but  because  the  spirit  of  sales- 
manship seemed  to  overshadow  a  desire  to  give  to 
the  profession  a  valuable  remedy  with  scientific 
reasons  therefor.  Detail  men  appeared  to  be  under 
the  hypnotic  influence  of  a  great  mass  of  ccise  re- 
ports, which  to  me  proved  little.  It  was  months  be- 
fore any  urologist  upon  whose  judgment  one  might 
depend  had  anything  to  say  on  the  subject. 

Some  of  my  confreres  in  general  practice  be- 
lieved that  phylacogen  was  of  great  value  while 
others  could  see  nothing  good  in  it. 

I  do  not  care  to  discuss  at  length  the  theoretical 
action  of  Shafer's  product,  but  in  a  judicial  spirit 
present  to  you  my  impressions  of  phylacogen  gained 
from  observation  of  a  comparatively  small  num- 
ber of  cases. 

In  acute  urethritis  I  have  little  to  say  in  favor 
of  phylacogen.  It  has  been  continually  noted,  while 
treating  complications  of  gonorrhea,  prostatitis,  vesi- 
culitis, arthritis,  etc.,  in  which  a  urethral  discharge 
has  been  present,  that  as  a  rule  the  discharge  and 
gonococci  remained,  however  the  complication  might 
have  been  influenced.  Six  cases  of  acute  urethritis 
were  treated,  three  without  result. 

To  one,  seven  doses  were  given  up  to  2|/2  c.c. 
He  left  towTi  much  improved  after  the  seventh  daily 
dose,  having  taken  no  other  treatment. 

Another  of  this  little  series  appeared  suffermg 
much  pain,  with  both  portions  of  urine  turbid,  Oct. 
6th,  1914.  He  was  given  phylacogen  minims  4 
and  was  much  relieved  the  following  day.  From 
this  time  fourteen  doses  from  Yl  c.c.  to  6  c.c.  were 
given  up  to  Oct.  26th.  Patient  was  discharged 
Oct.  28th  with  both  portions  of  urine  clear. 

I  may  say  that  we  have  employed  only  the  intra- 
venous method,  usually  beginning  with  Yl  c.c,  in- 
creasing or  decreasing  the  daily  dose,  attempting  to 
produce  a  slight  reaction. 


*Read  before  the  American  Urological  Association,  North 
Central   Section,  Chicago,   November    12th,    1915. 


[Reprinted    from    THE   UROLOGTC   AND   CUTANE- 
OUS REVIEW,  March.   1916.] 

56 


Of  cases  of  prostatitis,  that  is,  cases  in  which  the 
predominating  pathology  was  in  the  prostate  ten 
were  treated.  In  five  cases  we  report  no  result, 
while  treatment  was  more  or  less  beneficial  in  five. 
Dr.  Cole  reports  the  following  case: 

M.  T.,  age  20.  Urethral  discharge  off  and  on  for  past 
four  years.  Left  Grace  Hospital  two  months  ago,  where 
he  had  been  treated  five  weeks  for  rheumatism  (gonor- 
rheal). Has  taken  606.  At  present  there  is  urethral  dis- 
charge. He  complains  of  muscular  pains,  especially  in 
legs.  Prostate  is  slightly  enlarged  and  tender,  but  firm  to 
the  touch.  Prostatic  fluid  contains  pus  cells.  This  patient 
was  given  thirteen  doses  of  phylacogen  subcutaneously,  from 
1  to  10  c.c.  The  only  result  seemed  to  be  a  more  or  less 
severe    local    reaction. 

In  no  case  do  we  find  any  distinct  improvement  as  a 
result  of  the  administration  of  phylacogen,  in  chronic 
prostatitis,  vesiculitis  or  crypt  infection.  On  the  other  hand, 
let  me  report  a  case  or   two: 

Albert  A.  Noticed  fresh  urethritis  January  9th.  I  saw 
him  February  22nd.  Both  urines  were  turbid.  Right 
vesicle  and  right  prostatic  lobe  large  and  tender.  Pulse 
112;  temperature  100°.  Epididymis  also  swollen.  Six 
doses  phylacogen,  ]/2  to  3  c.c.  given.  February  26th,  many 
gonococci  noted.  February  27th,  epididymis  still  large  but 
less  painful.  March  2nd  and  6th,  urine  sparkling  but  in- 
filtration present  in  epididymis.     Patient  discharged. 

Geo.  M.  On  November  7th  both  urines  turbid.  Urinates 
every  twenty  minutes.  Bloody  discharge  from  urethra,  con- 
tains pus  and  gonococci.  Temperature  101°;  pulse  20. 
Gave  six  doses  J/2  to  2  c.c.  from  November  7th  to  1 2th. 
On  latter  day  temperature  was  normal  and  he  felt  good. 
Not  yet  well.  It  is  not  necessary  to  report  in  full.  This 
IS  one  of  a  series  of  cases  of  which  similar  ones  are  fre- 
quently seen.  No  one  can  tell  whether  such  prostates  will 
eventuate  in  prostatic  abscess,  although  I  think  it  is  the 
experience  of  all  of  us  that  rarely,  even  though  the  inflam- 
mation be  acute,  will  an  abscess  form  if  proper  treatment 
be    employed. 

Dr.  Seabury  reports:  A.  G.,  age  22.  Gonorrhea  five 
and  two  years  ago.  Present  attack  ten  days  ago,  four 
days  after  exposure.  Urethral  discharge  free.  Has  to 
urinate  three  or  four  times  at  night.  Perineal  pain.  Pros- 
tale  sensitive.  Both  urines  equally  turbid.  Temperature 
99.4°.  August  30th,  injected  100,000,000  dead  gonococci 
and  gently  irrigated  anterior  urethra  with  sol.  potassium 
permanganate. 

August  31.     Both  urines  turbid;   feels  belter;    temperature 

99.2°. 

Injected   200,000,000   gonococci. 

September    1st.      Temperature    99.8°.      Irrigated. 

September  3rd.  Temperature  98.4°.  No  pain.  Irrigated. 
Neglected  himself  until  September  13th,  when  left  lobe  of 
prostate  was  hot  and  larger  than  right.  Phylacogen  minims 
4   was   given. 

September  14th.  Much  belter.  Phylacogen,  minims  12, 
caused  chill. 

September  15th.  Pain  gone.  Prostate  smaller.  Phy- 
lacogen, minims   18. 

September  16th.  Feels  so  much  better  it  is  thought  safe 
to  resume  local  treatment.  October  5th,  urine  clear  but  few 
pus  can  be  expressed   from  prostate.      Improvement  marked. 

E.  P.  R.  Age  24.  Gonorrhea  two  weeks  ago,  two 
and  a  half  days  after  exposure.  Been  using  injections  of 
zinc  sulphate,  also  internal  treatment.  There  is  profuse 
purulent  discharge  containing  gonococci.  Both  urines  turbid. 
Irrigated  with  potassium  permanganate  once  a  day,  also  gave 
injection  of  protargol  1/5  per  cent,  four  times  a  day  until 
November  10th,  with  complete  cessation  of  discharge  after 
the  fourth  day.  On  the  lOlh  complained  of  perineal  pain. 
Right  lobe  prostate  tense  and  hot;  is  very  sensitive.  Was 
given    phylacogen,    five    doses    from    minims    5    to    20    until 


October    14th,   when  2nd  urine  was   sparkhng   and  first  was 
nearly  clear.     He  improved  steadily  until  well. 

We  think  that  in  prostatitis  one  does  not,  as  a 
result  of  the  administration  of  phylacogen,  expect 
any  miraculous  results.  We  believe  that  one  can 
not  expect  any  good  results  from  its  use  in  the 
chronic  forms  of  the  disease.  One  doubts  that  it 
has  any  effect  in  sterilizing  the  genital  tract  in  acute 
prostatic  infection,  but  we  do  feel  that  in  the  acute 
stages  of  prostatitis  in  connection  with  rest  in  bed 
and  possibly  the  use  of  the  psychrophore,  it  may  be 
cin  important  adjunct  to  treatment. 

Classed  as  acute  gonorrheal  epididymitis  in  our 
series  are  1 6  cases.  Of  these  we  believe  that 
twelve  showed  marked  improvement  as  a  result  of 
phylacogen,  one  doubtful  and  three  unimproved. 
We  realize  that  in  the  discussion  of  the  treatment 
of  epididymitis  we  tread  dangerous  ground,  for  no 
one  appreciates  better  than  the  writer  that  rest  alone 
will  start  many  so  far  on  the  road  to  recovery  that 
there  need  be  no  further  thought  as  to  medication  or 
operation.  Of  the  three  cases  not  improved,  one 
received  a  dose  of  Yl  cc.  but  would  not  accept 
another  treatment. 

Dr.  Seabury  reports:  N.  D.,  age  14.  No  previous 
venereal  disease.  Denies  exposure.  Gonorrhea  began  two 
weeks  previous  to  first  consultation.  Had  used  protargol 
injections.  Left  lobe  of  prostate  large,  hard  and  tender. 
Vesicles  and  vas  thickened.  Small  nodule  in  tail  of  left 
epididymis. 

July  18th.  All  local  treatment  stopped;  phylacogen, 
minims  4,   given. 

July  19th.  Feels  better.  Node  in  epididymis  increased 
in  size.  Vas  the  size  of  small  lead  pencil.  Gave  phylaco- 
gen,  minims  8. 

July  20th.  Feels  belter,  while  in  bed,  but  will  not  slay. 
Phylacogen,  minims   10,  given,  followed  by  chill. 

July  22nd.  Epididymis  large  but  pain  less.  Phylacogen, 
minims    1 5. 

July  23rd.  No  improvement  other  than  less  pain.  Phy- 
lacogen, minims   15. 

July  24lh.  Epididymis  somewhat  less  swollen.  Phy- 
lacogen, minims    15. 

July  25th.  Chill  and  headache  after  phylacogen,  minims 
20. 

Patient  was  out  of  bed  August  5th,  and  when  last  seen, 
September  22nd,  first  urine  was  slighly  turbid  and  second 
clear.  In  this  case  phylacogen  did  not  prevent  epididymis. 
The  doctor  is  confident  that  the  case  was  gonorrheal  with 
no  tubercular   tendency. 

Dr.  Cole  reports:  H.  T.,  age  20.  Gonorrhea  seven 
weeks  ago.  Three  weeks  later,  without  local  treatment, 
left  testis  began  to  swell.  After  six  days  in  Harper  Hos- 
pital he  was  discharged.  The  swelling  and  tenderness  of 
the  epididymis  nearly  gone.  Mild  irrigations  were  then 
used  and  swelling  recurred.  When  consulted  there  was 
urethral  discharge,  a  swollen  left  epididymis.  Left  vesicle 
palpable  and  tender  but  prostate  normal. 

From  September  24th  to  October  8th,  twelve  doses  of 
phylacogen,  from  Yl  c.c.  to  10  c.c.  were  given  subcu- 
taneously,  with  no  benefit.  Eighteen  days  after  first  dose 
testis  was  slightly  swollen,  no  tenderness,  no  discharge,  but 
both   urines   were   slightly    turbid. 

In  the  shortest  possible  manner,  let  me  report  a  few  other 
cases. 

L.  Right  epididymitis.  Three  doses  Yl  '<*  '  c.c.  Relief 
from   pain    the   only   effect. 

58 


W.  Epididymitis  and  prostatitis.  Five  doses  given.  Im- 
provement   was    steady. 

M.  Acute  epididymitis.  Temperature  100'.  One  dose. 
Much  better  the   following  day. 

N.     Acute  epididymitis.     One  dose.     No  other  treatment. 

M.  Acute  epididymitis.  Very  painful.  Temperature 
100.5  .  Four  doses  to  ]}/2  c.c.  were  given.  When  dis- 
charged  head   and    tail   were  still   large   but   not   painful. 

P.  H.  Noticed  left  epididymis  is  swollen.  September 
23rd.  When  seen  September  25th,  patient  had  not  slept  the 
previous  night  because  of  pain.  There  was  very  little  fluid 
in  the  tunica  vaginalis  but  the  swelling  was  the  size  of  a 
small  organge.  Phylacogen  1  c.c.  was  given.  September 
26lh.  Pain  gone;  swelling  much  less  and  he  left  the  hos- 
pital   that   afternoon. 

G.  H.  September  12th.  Moderate  swelling  of  left 
epididymis.  Temperature  100.4°.  Phylacogen  J/?  c.c.  given. 
September  14th.  Much  improved.  September  20th.  Urine 
clear.      Small   nodule   hardly   noticeable   in   epididymis. 

H.  B.  July  13th.  Pain  first  noticed  last  evening.  Is 
sick.  Pain  in  back  and  left  flank.  Left  testis  painful  and 
swollen.  Not  large.  Phylacogen  J/2  c.c.  given.  Went 
home  and  slept.  July  14th.  Reports  great  relief.  Eight 
doses   given   to  July  28th.      Urine   clear.      Feels  good. 

D.  M.  Three  months  ago  was  in  Chicago  Hospital  two 
weeks  with  swollen  left  testis.  I  saw  him  January  25th. 
He  had  pain  and  great  tenderness  in  swollen  left  testis. 
Was  given  two  doses,  J/2  and  1  c.c.  January  29th.  Pa- 
tient was  walking  about  with  little  pain.  In  this  case  swell- 
ing had  decreased  and  patient  noticed  a  marked  improve- 
ment. 

F.  V.  First  noticed  pain  and  swelling  two  weeks  before 
entering  hospital.  On  February  23rd,  right  testis  was 
found  to  be  large  and  lender.  Four  doses  of  phylacogen 
from  1  to  3  c.c.  were  given.  For  some  reason  temperature 
went  to  104°  on  the  25th  and  on  the  26th  with  tempera- 
ture 103.2°,  phylacogen  was  given.  Temperature  went  to 
104.4°,  then  dropped  in  a  few  hours  to  97.6°.  Patient  then 
improved   rapidly    and   was    discharged    March    1st. 

J.  S.  Patient  noticed  right  testis  swollen  May  13th. 
I  saw  him  May  18th.  Then  the  right  side  was  greatly 
swollen,  red  and  painful.  Phylacogen  was  given  for  the 
next  five  days  and  patient  kept  in  bed.  On  the  19th  testis 
was  less  tender  and  smaller.  On  the  20th  all  symptoms 
had  decidedly  improved;  on  the  2 1st  pain  had  gone  and 
he  was  discharged  on  the  24th,  the  swelling  having  nearly 
disappeared. 

This  was  a  fit  case  for  a  Hagner  but  patient  left  the 
hospital  about  the  same  time  as  did  another  man  upon 
whom  I  had  done  a  Hagner.  Both  were  well  marked, 
acute  cases,  with  just  about  the  same  conditions  present. 
Both  were  well  pleased  with  the  results  of  their  treatment. 
Although  I  am  sure  that  some  cases  are  better  and  more 
conservatively  treated  by  an  early  Hagner,  still  I  am  quite 
certain  that  others,  probably  many,  if  placed  in  bed  and 
given  phylacogen,  will  promptly  recover  without  a  surgical 
operation.  I  do  not  think  I  am  always  able  to  determine 
at  the  outset  just  the  cases  upon  whom  I  should  operate 
and  those  that  I  should  treat  more  conservatively.  My 
feeling  at  the  present  time  as  to  the  indications  in  epididy- 
mitis is  that  there  are  four:  Rest  in  bed  with  support  of  the 
scrotum,  saline  cathartics,  phylacogen  and,  if  pain  persists 
for  twenty- four  hours,  epididymotomy.  Many  patients,  when 
first  seen,  will  allow  an  operation,  but  few  will  consent  on 
the   second  day. 

Gonorrheal  Arthritis. — Of  my  sixteen  cases,  in 
one  there  was  no  improvement ;  questionable  in 
four,   and  marked  in  eleven. 

Dr.  Smith  reports  case  unimproved  as  follows: 

Frank  L.,  aged  23.  Gonorrhea  six  and  two  years  ago. 
About  one  month  after  last  attack  commenced  to  have 
pains  in  both  ankles  and  knees,  also  wrists  and  shoulders. 
At  time  of  first  consultation  pain  was  present  in  both  ankles 

59 


and  heels.  Both  hands  were  swollen  and  deformed.  Was- 
sermann  was  negative,  but  complement  fixation  for  gonor- 
rhea positive.  From  October  4th  to  November  7th,  twenty- 
three  injections  in  size  from  minimi  2  to  7  c.c.  were  given, 
absolutely   without   benefit. 

Of  the  four  cases  reported,  benefits  doubtful, 
one  was  not  completely  reported ;  another  was  given 
three  doses  and  improved  but  was  transferred  from 
hospital  to  county  house  before  a  reliable  report 
could  be  entered.  A  third,  seen  in  consultation, 
was  seriously  sick,  had  been  given  mixed  vaccine; 
at  my  suggestion  she  was  given  six  doses  phylacogen 
Yi  to  1  c.c.  All  but  one  produced  chill.  Tem- 
perature 101°,  not  raised  after  injection.  She  made 
a  good  recovery  but  it  was  thought  that  phylaco- 
gen did  little  more  good  than  vaccine.  Case  four 
I  will  report. 

Mrs.  H.  E.  D.,  aged  25.  Acute  gonorrheal  cervicitis. 
Seven  months  pregnant.  February  22,  complained  of  pain 
in  right  knee.  Received  50,000,000  dead  gonococci.  Next 
day  knee  was  worse,  and  cramps  in  lower  abdomen.  Up 
to  March  3rd,  used  10  c.c.  anti-gonococcic  serum.  Pain 
relieved  and  swelling  subsided;  developed  urticaria.  March 
10th  pain  in  knees  and  ankle  returned,  100,000,000  dead 
gonococci  given  and  on  the  1 3th  200,000,000  and  patient  was 
taken  to  hospital. 

March  14th.  Knee  badly  swollen;  pain  in  both  ankles 
and  sterno-clavicular  articulations,  also  7th,  8th  and  9th 
vertebrae. 

March  14th.  Phylacogen  Yl  c.c.  Chill.  Temperature 
100.2°- 103°.      Some    relief. 

March    15th.      Phylacogen    1    c.c.      Chill. 

March  1 6th.  Phylacogen  V/i  c.c.  Chill.  Rise  of  tem- 
perature   and    vomiting. 

March  17th.  Phvlacogen  2  c.c.  Severe  chill.  Rise  of 
temperature   to    104  . 

March    18th.      Phylacogen    2    c.c.      Severe    chill. 

March   19th.     Phylacogen  2  c.c.     Mild  chill. 

March   20th.      Phylacogen   2   c.c.      No   chill. 

March  18th.  Knee  aspirated  and  injected  with  formalin 
and    glycerin. 

March  28th.  Healthy  girl  delivered.  Previous  to  de- 
livery nothing  seemed  to  influence  the  joint  pains.  Phy- 
lacogen given;  only  partial  and  temporary  relief.  Follow- 
ing delivery,  all  pain  subsided.  Recovery  was  uneventful 
with  perfect  use  of  knee. 

Of  the  eleven  cases  in  which  good  results  are 
reported  the  following  short  reports  seem  to  me 
quite  convincing. 

A.  G.,  age  36.  April  28th.  Pain  between  shoulders 
in  right  shoulder  and  left  sterno-clavicular  articulation  and 
left  ankle.  Given  six  doses,  minims  6  to  22.  Felt  good 
May    10th   and   left    Harper    May    I7lh. 

O.  J.  Severe  gonorrhea  four  years  ago,  complicated  with 
prostatitis,  epididymitis,  arthritis,  lasting  several  months.  Nov. 
18th.  History  of  severe  gonorrhea.  Both  ankles  painful. 
Left  knee  tender  and  soft.  Temperature  100.6  .  Left 
knee  swollen,  tender  on  pressure.  Both  ankles  tender  back 
of  malleoli.  Prostate  normal  with  normal  secretion.  Sem- 
inal  vesicles  both   palpable   and   tender. 

Sodii  salicyl,  gr.  x  every  2  hours  for  two  days.  No 
change.  Left  wrist  is  stiff  and  sterno-clavicular  articula- 
tion swollen  and  tender.  Pulse  100.  Temperature  101  . 
Respiration  27.     Phylacogen,  minims  8. 

March  21st.  Came  to  office  feeling  fine;  complete  free- 
dom of  motion;    swelling  reduced.     Phylacogen,  minims   10. 

March  22nd.  Pain  relieved,  same  knee  swollen  and 
right  wrist  stiff.  Unable  to  walk.  Kept  still  and  he  was 
seen  March  24th  and  given  phylacogen,  minims  12.  Knee 
and  foot  strapped. 

60 


March  26th.  Felt  so  well  that  he  went  to  work  for  one- 
half  day.  March  29th.  Pain  in  opposite  knee  and  ankle 
and  right  wrist.  Phylacogen,  minims  16.  March  31st. 
Phylacogen  seven  doses  up  to  35  minims  given  to  April 
21st,  always  with  reaction.  Back  to  work  well  and  con- 
tinued  well   after   April   27th. 

Dr.  Smith  reports  T.  E.  Gonorrhea  July,  1914.  Three 
weeks  later  rheumatism.  October  22nd.  Swelling  and  pain 
of  feet  and  heels.  Acute  discharge.  From  October  22nd 
to  November  9th,  fourteen  doses  of  phylacogen  were  given 
from  J/^  c.c.  to  9  c.c.  Irrigations  were  also  given.  Patient 
discharged  November  1 0th,  cured  of  discharge  and  rheu- 
matism. It  seems  to  me  that  great  improvement  was  felt 
by  patient  or  he  would  not  have  returned  to  receive  the 
heavy   doses  every   day. 

J.  B.  After  epididymitis,  right  wrist  and  left  ankle 
swelled  and  becoming  painful.  Three  doses  given,  2  to  2.5 
c.c.  given  after  February  24th.  Discharged  March  3rd, 
relieved  of  pain. 

V.  S.  Gonorrhea  three  weeks  ago.  Pain  in  knees,  swell- 
mg  of  joints.  Tenderness  at  inner  condyle  of  tibia.  Eight 
doses  J/2  to  3  c.c.  from  February  9th  to  February  20lh. 
Walks  easily.  No  swelling,  no  pain.  Improvement  noted 
from   first   injection.      Discharge    continues. 

R.  B.  Rheumatoid  arthritis  at  age  10,  also  at  18  and 
22.  This  attack  began  January  1st,  1915.  Pain  passed 
from  joint  to  joint.  Salicylates  do  not  relieve.  January 
9th,  both  ankles  swollen  and  hot.  Comp.  fixation  test  for 
gonorrhea  positive.  Phylacogen  1  to  4  c.c.  given,  in  all 
six  doses.  No  chill  or  rise  of  temperature.  After  fourth 
dose  swelling  gone.  Treatment  began  January  9th;  was 
greatly  improved  by  the  16th  and  patient  discharged  feeling 
good  on  the  21st. 

S.  B.  Gonorrhea  one  month  ago.  Pains  without  swell- 
ing in  left  side  of  chest,  left  ankle  and  hip.  Pain  had  been 
severe  for  a  week  previous  to  treatment.  This  markedly 
decreased  after  second  dose.  After  nine  doses  from  De- 
cember 9th  to  December  27th,  patient  was  discharged  much 
improved. 

Dr.  Cole  reports  a  typical  case  of  gonorrheal 
arthritis  going  on  to  complete  recovery  after  thirteen 
injections  from  |/2  c.c.  to  4|/2  c.c. 

Without  wearying  you  with  further  details,  I 
would  conclude  from  these  meagre  observations  that 
phylacogen  in  acute  gonorrheal  arthritis  is  a  specific 
and  may  be  given  with  great  assurance  of  success. 

That  in  epididymitis  phylacogen  is  of  great  value 
in  many  cases.  It  is  not,  however,  to  be  relied  on 
to  the  exclusion  of  operative  treatment. 

That  in  acute  prostatitis  the  results  have  been 
sufficiently  encouraging  to  lead  one  to  further  ex- 
perimentation. 

In  chronic  prostatitis  one  must  depend  upon  old 
time  tested  methods  of  treatment ;  probably  phylaco- 
gen is  of  no  value. 

Finally,  the  writer  finds  no  place  for  phylacogen 
in  acute  gonorrheal  infection  of  the  urethra. 

In  the  above  compilation  we  wish  to  thank  Drs. 
Cole,  Smith,  Dodds,  Keane  and  Seabury  for  their 
collaboration. 


61 


SYPHILIS  OF  THE  PROSTATE.* 

By   a.    Ravocli,    M.    D.,    Cincinnati,    Ohio. 

A  few  years  ago  a  chapter  on  the  syphihtic  af- 
fections of  the  prostate  was  dismissed  with  these  re- 
marks, "Observations  on  affections  of  the  prostatic 
gland  are  also  very  few  in  number."  Eugene  Ful- 
ler ( I  )  emphasized  this  statement  by  writing  that 
this  gland  seems  to  be  peculiarly  exempt  from  syph- 
ilis in  any  of  its  stages  of  development.  Guyon 
and  Leanois  on  Prostatismus  referred  the  prostatic 
hypertrophy  to  a  process  of  arteriosclerosis.  In  so 
far  that  arteriosclerosis  more  frequently  affects  in- 
dividuals who  have  had  syphilis,  in  this  distant  way 
some  authors  have  tried  to  connect  syphilis  with 
prostatic  affections. 

The  difficulty  of  ascertaining  the  syphilitic  origin 
of  the  prostatic  affections  rests  in  the  frequency  of 
the  allied  disease  gonorrhea,  which  often  is  found 
in  the  same  patient  at  the  same  time.  It  cannot  be 
denied  that  the  principal  cause  of  prostatitis,  often 
acute  or  chronic  type,  is  gonorrhea  with  its  conse- 
quences, strictures,  cystitis,  etc.  On  the  other  hand 
nobody  can  deny  that  syphilis,  which  affects  every 
tissue  of  the  human  body,  spares  the  prostate  for 
the  only  reason  that  it  can  not  be  easily  seen. 
Reliquet,  Rochon,  Duhot,  Grosglick  and  others 
have  referred  to  cases  of  syphilis  of  the  prostate. 
Michailoff  (2)  reported  a  case  of  recurrent  hema- 
turia in  a  woman,  where  the  cystoscopic  examina- 
tion showed  many  superficial  ulcerations  in  the  mu- 
cosa of  the  bladder.  Wassermann  positive,  specific 
treatment  cured  the  hematuria.  A  case  of  reten- 
tion of  urine  due  to  syphilis  was  reported  by  Much- 
arinsky  (3).  The  prostate  was  enlarged,  the  urine 
cloudy.  Cystoscopic  examination  showed  some 
hypertrophy  of  the  middle  lobe  of  the  prostate,  and 
in  immediate  proximity  to  the  bladder  was  found  a 
deep  ulcer.  The  mucous  membrane  of  the  bladder 
showed  marked  hyperemia,  in  the  form  of  reddish 
areas,  round,  suggesting  erythema.  The  diag- 
nosis was  that  of  secondary  syphilitic  erythema  of 
the  bladder,  and  syphilitic  ulcer  of  the  prostate. 
Antiluetic  treatment  showed  beneficial  results,  the 
ulcer  healing  up  in  a  short  time. 

Bransford  Lewis  (4)  in  some  obscure  forms  of 
prostatic  obstruction  pointed  to  the  possibility  of 
local  luetic  affections  of  this  organ.  In  many  cases 
diseases  of  the  cord  and  of  the  nervous  system  from 
lues  are  first  revealed  through  disturbances  in  the 
urination,  while  other  symptoms  had  passed  unob- 
served. In  many  cases  the  Wassermann  test  is 
changing  the  significance  of  some  urinary  obstruc- 
tions, and  a  syphilitic  condition  may  be  found  at 
the  bottom  to  explain  some  prostatic  alterations. 


*Read  before  the  American  Urological  Association,  North 
Central   Section,  Chicago,   November    12th,    1915. 


[Reprinted    from    THE   UROLOGIC   AND    CUTANE- 
OUS REVIEW,   March,   1916.] 

G2 


In  some  obscure  cases  of  urinary  retention,  when 
the  Wassermann  is  positive,  Philip  Kreissl  has  ob- 
tained brilliant  results  by  the  intravenous  administra- 
tion of  salvarsan.  In  a  series  of  cases,  which  he 
kindly  showed  me,  the  antisyphilitic  treatment  had 
been  very  valuable.  It  must  be  combined  with 
local  treatment  which  he  does  by  mjecting  into  the 
prostatic  urethra  a  mild  solution  of  1  to  5,000  of 
silver  nitrate. 

It  is  not  only  in  acquired  syphilis  that  symptoms 
of  urinary  retention  may  be  produced,  but  also  in 
hereditary  lues  it  is  found  that  this  is  the  cause  of 
urinary  disturbances  difficult  to  diagnose.  Enuresis 
nocturna  in  boys  and  girls  has  been  referred  to 
hereditary  lues.  Indeed  Bransford  Lewis  refers  to 
cases  of  retention  of  urine  without  obstruction,  in 
which  only  the  Wassermann  test  was  able  to  ex- 
plain the  true  origin.  Some  cases  have  to  be  con- 
sidered as  cases  of  incoordinative  retention,  which 
is  the  result  of  spinal  degeneration.  On  account  of 
impaired  action  on  the  vesical  nerves  the  function 
of  the  detrusor  is  incomplete  and  it  simulates  a 
relative  sphincteric  obstruction. 

The  object  of  this  paper  is  to  call  attention  to 
the  syphilitic  manifestations  and  to  syphilitic  pro- 
cess which,  in  the  various  stages  of  the  disease, 
may  affect  the  prostate  in  the  same  way  that  any 
other  organ  of  the  body  is  subject  to  its  attacks. 
We  will  therefore  consider  the  manifestations  of 
syphilis  in  the  prostate  in  the  early  period  of  the 
disease,  and  then  in  the  late  gummatous  period. 

In  the  secondary  period  of  syphilis  the  prostatic 
urethra  is  affected  with  superficial  ulcerations  of 
the  condylomatous  or  papular  type,  which  are  re- 
vealed by  the  urethroscope.  In  these  cases  the  in- 
troduction of  a  sound  is  very  painful,  and  although 
done  with  the  greatest  care  it  causes  bleeding,  due 
to  the  excoriating  of  the  granulations  on  the  sur- 
face of  the  ulcerations.  To  this  condition  we  at- 
tribute bloody  ejaculations,  since  in  the  very  few 
instances  we  have  seen  it  was  in  individuals  whose 
principal  trouble  was  syphilis. 

Syphilis  in  the  secondary  period  affects  the  tract 
of  the  prostatic  urethra  in  the  form  of  a  superficial 
ulcerative  process.  These  superficial  ulcerations 
may  remain  limited  to  the  prostatic  urethra,  while 
in  some  cases  they  may  extend  to  the  bladder,  as 
shown  by  the  cystoscopic  examination. 

From  a  number  of  clinical  cases  we  select  one 
in  which  the  syphilitic  manifestations  in  the  pros- 
tatic portion  of  the  urethra  were  clear. 

A.  S.,  32,  married,  telegraph  operator,  robust,  in  good 
physical  condition.  He  has  had  several  gonorrheal  attacks, 
of  which  he  has  been  cured.  Some  two  years  ago  he  had 
syphilitic  infection,  for  which  he  took  mercurial  treatment 
and  one   full  dose  of  salvarsan. 

He  asked  for  medical  attendance,  in  order  to  be  relieved 
of  a  painful  and  frequent  micturition,  which  prevented  him 
from  sleeping  and  interfered  with  his  work.  The  exam- 
ination of  the  urine  in  two  glasses  showed  first  urine  cloudy 
with  shreds  and  some  mucopus,  second  urine  less  cloudy, 
the   last   drop    expelled   with   pain    and    tenesmus.      A   sound 

63 


was  introduced  to  ascertain  the  condition  of  the  urethral 
mucosa.  In  withdrawing  the  sound  it  gave  the  sensation  of 
some  hardenmg  m  the  bulbar  region.  Exammation  per 
rectum  found  the  prostate  slightly  enlarged  with  a  few  ir- 
regular nodules  in  its  surface.  The  posterior  urethra  and 
the  bladder  was  irrigated  with  a  solution  of  potassium  per- 
manganate 1  to  5,000.  From  this  treatment  the  patient 
had  no  relief,  and  was  compelled  to  remain  in  bed  the 
following  day.  After  the  acute  symptoms  had  subsided,  by 
means  of  the  urethroscope  there  were  found  two  ulcera- 
tions of  the  size  of  a  lentil,  round  in  shape  and  easily 
bleeding,  in  the  lumen  of  the  prostatic  urethra.  The  ul- 
cerated spots  were  touched  up  with  3  per  cent,  solution  of 
nitrate  of  silver.  A  few  days  after  by  means  of  the  cysto- 
scope  the  bladder  was  examined  which  showed  only  some 
hyperemia  towards  the  urethral  end.  The  patient  had  a 
positive  Wassermann  and  was  again  subjected  to  antiluetic 
treatment.  By  means  of  the  urethroscope  the  ulcerations 
in  the  prostatic  urethra  were  treated  locally  and  in  a  short 
lime  healed  up  completely.  The  urine  returned  clear,  the 
frequency  diminished,  and  the  patient  returned  to  his  work. 

Several  other  cases  of  the  same  kind  could  be 
reported,  where  a  luetic  ulcerative  process  was 
found  in  the  prostatic  urethra,  all  of  which  by  local 
and  general  treatment  were  benefited.  The  pres- 
ence of  ulcerations  in  the  prostatic  urethra  is  an 
open  door  for  bacterial  infection  to  the  body  of  the 
prostate  causing  prostatitis,  which  may  end  in  cin 
abscess. 

In  the  tertiary  stage  of  syphilis  the  prostate  may 
be  affected  in  its  lobes  in  form  of  gumma  causing 
the  swelling  of  the  affected  lobe,  and  producing 
some  obstruction.  The  gumma  is  developed  in  the 
parenchyma  of  the  gland,  and  undergoes  its  path- 
ological changes,  either  by  reabsorption  or  by  break- 
ing down.  A  well  defined  case  occurred  in  our 
practice. 

P.  N.,  an  Italian  barber,  45,  had  suffered  from  syphilis 
for  over  i  5  years.  For  a  long  time  no  symptoms  had  re- 
turned. One  of  his  children  had  a  periosteal  gumma  of  the 
right  arm,  which  yielded  to  mixed  treatment.  He  came  to 
be  treated  on  account  of  an  unbearable  pain  deep  in  the 
perineum  and  rectum  together  with  tenesmus  of  the  bladder 
and  rectum.  He  complained  of  frequent  urination  together 
with  pain,  no  relief  after  urinating;  there  remained  some 
urine  which  could  not  be  expelled  on  account  of  pain.  The 
stream  of  urine  was  small,  without  propulsion;  difficult  to  start, 
ending  in  drops.  A  sound  could  not  be  introduced  on  ac- 
count of  pain.  The  exploring  finger  in  the  rectum  found  a 
swollen  prostate  bulging  like  a  ball,  painful  to  the  touch, 
somewhat  softer  in   the  middle. 

It  was  decided  to  incise  the  perineum  and  perform  a 
prostatolomy.  Under  a  general  anesthesia  the  perineum  was 
opened,  the  prostate  isolated,  the  capsule  incised  and  bloody, 
grumous,  purulent  matter  removed.  The  surface  was  cleaned 
with  dull  curette,  and  packed  with  iodoform  gauze. 

In  a  short  time  recovery  was  perfect.  Wassermann 
proved  slightly  positive,  and  antiluetic  treatment  with  grey 
oil  and  potassium  iodide  was  instituted.  The  man  is  work- 
ing every  day  and  has  never  had  any  further  urinary  dis- 
turbance. 

This  case  has  been  reported  as  one  of  syphilitic 
gumma  of  the  prostate,  as  it  seems  to  show  clearly 
the  luetic  origin.  Other  cases  have  been  treated 
where  no  surgical  interference  was  required  and  an 
antisyphilitic  treatment  especially  with  salvarsan 
was  able  to  relieve  the  urinary  troubles. 

64 


An  interesting  point  is  to  find  the  differential 
characters  between  syphihtic  prostatitis  and  gonor- 
rheal prostatitis.  The  prostate  is  a  point  of  predi- 
lection for  the  gonococci,  which  enter  its  excretory 
ducts  and  the  ejaculatory  ducts.  Nearly  all  the 
patients  who  have  suffered  with  chronic  gonorrhea 
of  the  posterior  urethra  have  suffered  with  chronic 
prostatitis.  The  combination  of  both  infections 
may  have  some  influence  one  on  another,  as  a  result 
of  pars  minoris  resistenliae.  Yet  in  the  individual 
cases  a  differential  diagnosis  is  made,  by  the  face 
of  the  presence  of  syphilis,  by  the  persistence  of  the 
symptoms  in  spite  of  the  amtigonorrheal  treatment, 
by  the  urethroscopic  and  cystoscopic  examination, 
which  shows  the  presence  of  limited  ulcerations  in 
the  prostatic  urethra.  In  the  case  of  a  prostatic 
abscess  resulting  from  gonorrheal  or  from  any  other 
bacterial  origin  the  inflammatory  process  is  much 
more  acute,  and  soon  breaks  either  into  the  perineum 
or  rectum. 

In  conclusion  we  believe  that  the  prostate  is  not 
immune  from  syphilitic  attacks,  that  in  the  secondary 
period  the  prostatic  urethra  shows  m  its  mucosa 
local  papular  superficial  erosions  of  the  condyloma- 
tous  type,  in  the  tertiary  period  the  parenchyma  of 
the  gland  is  affected  in  the  form  of  gumma  with  all 
its  consequences. 

REFERENCES. 

1.  Annales  des  Maladies  des  Organei  Can.  Urin.,  Feb. 
1889,  quof.  by  Fuller. 

2.  Michailoff,  N.  A.:  Syphilis  der  Hernblase  und  der 
Oberen  Harnwege.  Zeitschrifi  fur  Urologie,  1912,  2  Heft., 
p.  215. 

3.  Mucharinsky,  M.  A.:  Zur  Frage  der  Harnblasen 
Syphilis.     Zeilschnft  f.  Urologie,  1912,  H.  5,  p.  376. 

4.  Bransford,  Lewis:  Studies  in  Obscure  Forms  of 
Prostatic  Obstruction  and  Vesical  Atony.  Annals  of  Sur- 
gery, March.   1915,  p.  277. 


65 


CLINICAL  REVIEW  OF  240  GASES  OF 

NON-SURGICAL     INFECTION     OF 

THE  KIDNEYS  AND  URETERS.- 

Bv  Gilbert  J.  Thomas,  M.  D.,  Rochester,  Minn., 
Ma\)o    Clinic. 

In  an  attempt  to  discover  the  predisposing  fac- 
tors, if  any,  in  non-surgical  infection  of  the  kid- 
neys and  ureters  and  to  determine  the  relative  value 
of  the  present  modes  of  treatment  I  have  consid- 
ered m  this  study,  antecedent  infections,  pre- 
vious operations,  etc.  T  he  symptoms  of  onset  and 
those  of  most  common  occurrence  during  the  pro- 
gress of  the  disease  have  been  analyzed  together 
with  cystoscopic  and  bacteriologic  findings.  Stones 
in  the  bladder,  kidney  or  ureter  and  obstruction  in 
the  lower  urinary  tract  have  been  excluded. 

Such  infections,  except  those  due  to  obstruc- 
tion in  the  lower  urinary  tract,  are  hematogenous 
in  origin.  In  the  infections  due  to  obstruction  the 
lymphatics  probably  play  a  part  in  carrying  the  in- 
fection to  the  kidney.  It  is  possible  that  they,  also, 
are  of  hematogenous  origin  and  that  obstruction 
lessens  resistance  by  mechanical  means  and  is  the 
predisposing  factor,  not  the  cause,  of  the  infection. 

Brewer  ( 1  )  states  that  all  renal  infections  are 
hematogenous,  including  those  that  come  from  an 
infection  primary  to  the  bladder.  Sweet  and 
Stewart  (2)  after  careful  anatomic  and  experi- 
mental study  have  concluded  that  the  lymphatics 
of  the  bladder,  ureter  and  kidneys  anastomose  rather 
freely  and  that  they  can  carry  infection  from  the 
bladder  to  the  kidney.  They  believe  this  route 
of  infection  is  frequently  the  one  by  which  the 
pelvis  and  parenchyma  of  the  kidney  become  in- 
fected from  the  infection  in  the  bladder.  Cabot 
(3)  and  others  believe  that  in  cases  in  which  there 
are  a  great  many  elements  in  the  urine  and  few 
symptoms  are  lymphatic  in  origin,  while  those  show- 
ing few  such  elements  and  marked  general  symp- 
toms are  hematogenous  in  origin. 

The  present  study  comprises  a  review  of  240 
patients  who  received  urologic  treatment  in  the 
Mayo  Clinic  from  January  19,  1910,  to  January 
19,  1915;  32.8  per  cent,  were  women  and  67.2 
per  cent.  men.  The  average  age  of  onset  was 
30.3  years.  The  duration  of  symptoms  ranged 
from  two  weeks  to  twenty  years.  Twenty-six  per 
cent,  of  the  patients  did  not  give  a  history  of  pre- 
vious diseases ;  1 8  per  cent,  had  infections  of  the 
genital  tract,  giving  a  history  of  gonorrhea  or  pelvic 
infection ;  1  2  per  cent,  had  had  a  previous  attack 
of  typhoid  fever ;  9  per  cent,  gave  a  history  of 
childhood  infections;  6  per  cent,  of  pneumonia;  3 
per  cent,  of  tonsillar  infection ;  4  per  cent,  of  arth- 


*Read  before  the  American  Urological  Association,  North 
Central   Section.   Chicago,   November    12th,    1915. 


[Reprinted    from   THE   UROLOGIC   AND    CUTANE- 
OUS REVIEW,   March,   1916.] 

66 


ritis  and  rheumatism ;  4  per  cent,  of  scarlet  fever ; 
2  per  cent,  of  empyema  of  the  antrum  and  chronic 
aoscesses;  2-|-  per  cent,  of  syphihs,  and  five  gave  a 
history  of  severe  abdominal  injury.  The  remain- 
mg  patients  gave  histories  of  infections  as  follows: 
Lung,  one;  ruptured  urethra,  one;  phimosis,  one; 
dysentery,  one;  malaria,  four;  pregnancy,  two;  etc. 
Of  the  240  cases  the  first  symptom  complained 
of  was  frequency  of  urination;  it  was  also  the  most 
common  symptom,  being  present  in  76  per  cent, 
of  cases,  and  varied  in  mtensity  from  voiding  every 
ten  minutes  to  one  or  two  times  per  night.  In  37 
per  cent,  pain  was  the  primary  symptom.  In  the 
analysis  of  pain  as  a  symptom  it  was  found  that 
severe  lumbar  attacks  were  complained  of  in  about 
20  per  cent,  of  all  the  cases;  a  dull  ache  across  the 
lumbar  area  and  sacrum  was  frequently  described. 
Epigastric,  lower  abdominal  and  vesical  pain  was 
frequent.  Painful  and  burning  urination  occurred 
at  some  time  during  the  history  in  60  per  cent. 

Patients  noted  hematuria  as  the  first  symptom  in 
7  per  cent,  and  it  was  noted  at  some  period  of  the 
history  in  4 1  per  cent,  of  the  cases.  In  2  per  cent, 
temperature  and  chills  were  the  first  symptom,  these 
symptoms  being  present  in  25  per  cent,  of  cases. 
Pyuria  was  a  primary  symptom  in  2  per  cent.  An 
appreciable  loss  of  weight  was  noted  in  41  per 
cent.  Gastric  and  duodenal  lesions  were  suspected 
m  a  number  of  cases  because  of  reflex  pain  which 
was  probably  of  renal  and  ureteral  origin.  In  a 
small  percentage  these  attacks  were  persistent,  un- 
relieved by  urologic  treatment,  and  required  surgical 
measures. 

C})stoscopic  Diagnosis. — Cystoscopic  examina- 
tion demonstrated  the  existence  of  bilateral  infec- 
tion in  1  74  (73  per  cent.)  patients.  The  infection 
was  confined  to  the  right  side  in  67  per  cent. ;  in 
eighteen  (7  per  cent.)  the  infection  was  on  the 
left  side  only.  Fifty-one  cases  were  diagnosed  as 
pyelitis,  five  of  which  were  of  a  chronic,  bleeding 
type.  In  our  experience  the  differential  diagnosis 
between  pyelitis  and  pyelonephritis  has  been  rather 
difficult.  Acute,  repeated  attacks,  with  micro- 
scopic findings  in  the  urine,  that  quickly  subside 
with  or  without  treatment,  may  be  regarded  as  in- 
fections of  the  pelvis  alone.  The  chronic  refrac- 
tive type  which  shows  few  elements  in  the  urine 
may  be  considered  as  pyelonephritis.  The  infec- 
tion found  in  pregnant  women  is  usually  a  pyelitis; 
it  is  to  be  noted  that  these  patients  are  relieved  as 
soon  as  the  uterus  is  emptied  and  good  drainage 
restored.  In  only  a  few  of  these  cases  does  the 
parenchyma  become  involved.  An  illustration  of 
the  somewhat  acute,  temporary  infection  of  the 
pelvis,  or  pyelitis,  is  shown  in  the  many  instances 
of  post-nuptial  infection.  These  cases  quickly  clear 
up  by  means  of  urotropin  and  other  simple  methods 
because  the  parenchyma  is  probably  not  involved. 
We  have  observed  two  very  interesting  cases  of 
post-operative  infection   of  hematogenous  origin   in 

fi7 


which  the  bacillus  tuberculosis  was  found  to  be  the 
causative  organism.  Both  patients  developed  acute 
cystitis  and  showed  bacilli  in  specimens  of  urine 
from  the  bladder.  In  one  there  were  tubercle  bac- 
illi in  both  ureteral  specimens.  These  patients  were 
relieved  by  urinary  antiseptics  and  hygienic  treat- 
ment. Repeated  exammations  after  the  acute  symp- 
toms had  subsided  failed  to  demonstrate  the  or- 
ganisms. One  patient  has  remained  well  for  one 
year  and  no  focus  of  infection  can  be  found.  There 
had  been  a  tonsillectomy  a  short  time  precedmg 
the  onset  of  cystitis.  One  patient  was  well  one 
month  after  the  acute  onset.  Guinea-pig  inocula- 
tion was  negative  in  one  after  three  months. 

In  our  hands  renal  functional  tests  have  not  al- 
ways proved  satisfactory  in  the  differentiation  be- 
tween pyelitis  and  pyelonephritis.  Equal  function 
in  the  two  kidneys  has  frequently  been  observed 
in  cases  in  which  the  pyelograms  demonstrated  one 
kidney  badly  damaged.  In  those  showing  infec- 
tion active  on  one  side  and  inactive  on  the  other, 
the  difference  in  function  may  not  be  great  enough 
to  be  of  value.  In  some  cases  one  kidney  with  a 
quantity  of  pus  would  show  as  large  an  output  of 
the  drug  as  the  kidney  with  no  bacteriologic  or 
chemical  findings.  However,  when  one  kidney  is 
largely  destroyed,  the  difference  in  function  when 
using  the  dyes  has  been  great  enough  to  direct 
suspicion  to  the  destroyed  kidney. 

Pyelogram. — The  pyelogram  will  differentiate 
a  marked  infection  of  the  parenchyma  from  one 
in  the  pelvis.  Infection  in  the  parenchyma  shows 
but  slight  inflammatory  changes  in  the  pelvic  out- 
line, while  a  pelvic  infection  usually  shows  marked 
inflammatory  changes.  This  means  of  differentia- 
tion has  also  been  of  considerable  aid  in  separating 
the  cases  of  actual  pyonephrosis  from  the  milder 
grades  of  infection,  seven  cases  having  been  found 
in  which  one  kidney  was  largely  destroyed.  It 
may  also  be  of  value  in  determining  the  etiologic 
factor.  Congenital  anomaly  in  the  urinary  tract, 
which  may  have  been  an  etiologic  factor,  was  found 
in  four  cases.  Obstruction  in  the  lower  ureter  was 
demonstrated  by  means  of  the  pyelogram  in  sev- 
eral cases  as  the  probable  cause  of  renal  infection. 

Cysliih. — A  marked  degree  of  cystitis  was  noted 
in  1 6  per  cent,  of  the  cases  while,  as  mentioned 
above,  the  most  common  symptom  (frequency  of 
urination)  was  noted  in  76  per  cent,  of  cases.  The 
bladder  does  not  always  show  marked  signs  of 
infection,  as  is  shown  by  this  series  wherein  25  per 
cent,  had  no  cystoscopic  evidence  of  cystitis.  All 
of  these  patients,  however,  had  varying  amounts  of 
pus  in  the  urine,  yet  34  per  cent,  had  no  symptoms 
referable  to  the  bladder.  A  considerable  number 
of  cases  of  renal  infection  have  been  diagnosed  only 
after  careful  and  repeated  cystoscopic  examinations. 
Many  showing  only  a  few  pus  cells  at  the  time 
of  the  first  examination,  on  re-examination  showed 
larger   amounts  of  pus   from  one  or   both   kidneys 

68 


and  vice  versa.  A  number  of  patients  with  irrita- 
bility of  the  bladder  and  no  microscopic  findings 
in  the  urine  have  shown  bacterial  growth  from  ca- 
theterized  urine  from  both  kidneys.  In  our  ex- 
perience cystitis  is  not  a  necessary  finding  in  renal 
infection.  Vesical  irritability  is  a  more  constant 
sign  than  cystoscopic  evidence  of  cystitis  but  both 
these  findings  may  be  absent  in  the  presence  of  a 
renal  infection. 

Bacteriologic  Examinalion. — Records  of  com- 
plete bacteriologic  examinations  were  available  in 
95  cases ;  63  per  cent,  were  of  the  colon  group. 
The  other  organisms  were  pyocyaneus,  micrococcus 
urea,  pneumococcus,  streptococcus  and  the  staphy- 
lococcus group.  It  is  probable  that  the  bacillus  coli 
is  a  secondary  invader  in  a  large  percentage  of  these 
infections.  The  offending  organism  and  its  toxins 
probably  lessen  the  resistance  of  the  kidney  so  that 
the  colon  bacillus,  which  is  constantly  passing 
through  the  kidney  becomes  pathogenic.  Many 
writers  are  of  the  opinion,  however,  that  the  pyelitis 
of  pregnancy  and  the  infections  which  accompany 
constipation  are  primarily  of  colonic  origin.  The 
stagnation  due  to  pressure  from  the  uterus  on  the 
intestine  and  resulting  constipation  are  factors  which 
probably  predispose  the  kidney  and  ureter  to  colon 
infection.  The  pressure  of  the  uterus  on  the  ureters 
interferes  with  their  function  and  thus  lessens  their 
resistance  to  mfection. 

When  symptoms  are  suggestive  of  tuberculosis, 
guinea-pig  inoculation  is  desirable.  This  was  found 
necessary  to  complete  the  diagnosis  in  48  cases.  In 
our  experience  absence  of  pus  or  no  growth  on  cul- 
ture does  not  necessarily  mean  a  single  infection. 
Inactive  infection  has  frequently  been  found  on  one 
side  by  microscopic  and  bacteriologic  examinations 
which  could  be  demonstrated  at  other  times  as  being 
active.  It  would  be  well  to  consider  a  non-tubercu- 
lous, non-calculous,  unilateral  infection  as  part  of 
a  bilateral  condition  until  by  pyelographic  and  cul- 
tural examinations  one  kidney  has  been  proved  to  be 
sound. 

In  making  cultures  of  urinary  infections,  con- 
tamination of  the  specimen  obtained  would  fre- 
quently negate  the  value  of  the  bacteriologic  ex- 
amination. Such  contamination,  in  our  experience, 
has  been  due  to  faulty  technic  in  that  all  instru- 
ments used  were  not  completely  sterilized.  Ure- 
teral catheters  are  not  easily  sterilized  as  may  be 
proved  by  cultures  made  from  bits  of  catheters 
which  are  in  daily  use  and  which  are  thought  to  be 
sterile.  The  ureteral  catheter  should  be  boiled  or 
should  be  made  sterile  in  some  manner  so  that 
when  sections  are  introduced  into  several  culture 
media  no  growth  can  be  obtained.  The  use  of 
unsterile  lubricants  is  also  a  frequent  source  of  con- 
tamination. Catheters  or  containers  which  have 
I'ust  been  removed  from  an  antiseptic  solution  have 
been  the  frequent  cause  of  a  report  of  no  growth 
when    later    examinations    demonstrated    organisms 

69 


present.  A  small  amount  of  such  solutions  in  cul- 
ture media  will  prevent  growth.  Cultures  should 
be  grown  both  aerobically  and  anaerobically. 

Treatment. — A  careful  search  for  foci  of  in- 
fection, such  as  tonsils,  teeth,  abscesses,  furuncu- 
loses,  bone  infections,  etc.,  should  be  made  before 
any  local  or  urologic  treatment  is  instituted.  Chronic 
abdominal  complaints  and  any  pathologic  condi- 
tion which  might  harbor  infection  should  be  search- 
ed out  and  completely  eradicated.  As  mentioned 
above,  26  per  cent,  of  patients  gave  a  history  of 
having  had  no  serious  illness  or  infection  which 
might  pave  the  way  for  chronic  renal  disease.  It 
is  safe  to  assume  that  many  of  these  patients  had 
forgotten  the  furunculosis,  the  severe  attack  of 
tonsillitis,  the  chronic  suppurative  ear,  the  chronic 
infectious  diseases  of  childhood  which  at  the  time 
seemed  trivial.  It  is  also  probable  that  organisms 
frequenting  tonsils,  carious  teeth,  appendix  or  gall- 
bladder may  be  so  changed  in  charatcer,  as  Rose- 
now  (4)  has  demonstrated,  as  to  have  a  special 
affinity  for  the  urinary  organs  at  certain  times. 
The  ever  present  colon  bacillus  quickly  outgrows 
the  organism  of  primary  infection  so  that  in  most 
chronic  cases  the  true  offending  bacteria  are  not 
always  found.  Autogenous  vaccines  were  given 
when  obtained  in  pure  culture  and  when  the  tol- 
erance of  the  patient  would  permit. 

Local  treatment  consists  of  regular  lavage,  at 
four  or  five-day  intervals,  of  the  kidney  pelvis, 
ureter  and  bladder.  For  this  purpose  silver  ni- 
trate, argyrol,  colloidal  silver,  protargol  and  silver 
iodid  have  been  used.  Many  of  the  patients  were 
given  urinary  antiseptics  by  mouth.  Silver  nitrate, 
beginning  with  .5  to  1  per  cent,  in  strength  and  in- 
creasing to  2  or  3  per  cent,  has  proved  the  best 
solution  for  lavage  of  the  pelvis.  Aluminum  ace- 
tate, in  our  hands,  did  not  prove  efficacious  and  was 
unsatisfactory  because  of  the  reaction  it  frequently 
occasioned  even  when  freshly  made  and  diluted. 
Weak  solutions  of  argyrol  and  the  other  colloidal 
silver  solutions  were  used  in  the  severe  acute  infec- 
tions where  reaction  was  feared. 

Surgery  becomes  the  logical  treatment  when  a 
single  infection  is  persistent  with  marked  constitu- 
tional symptoms,  even  in  the  presence  of  mild  infec- 
tion on  the  other  side.  Inflammatory  obstruction 
of  the  ureter,  pyelitis  granulosa  with  persistent 
bleeding  and  extensive  distention  from  infection  with 
destruction  of  renal  tissue  are  also  indications  for 
surgical  interference. 

To  ascertain  the  effect  and  permanency  of  the 
different  methods  of  treatment  a  circular  letter  was 
sent  to  each  of  our  patients  and  1  50  definite  an- 
swers were  received.  A  tabulation  of  these  an- 
swers shows  that  the  condition  was  stationary  in  44 
(29  per  cent.)  of  the  patients;  improved  in  70 
(46  per  cent.)  ;  and  that  recovery  was  complete 
in  28  (18  per  cent.).  Eight  of  these  patients  have 
since  died  and  the  reports  show  that  in  over  50 

70 


per  cent,   the  fatal   outcome  was  probably   due  to 
severe  renal  lesions. 

A  more  minute  analysis  of  these  answers  rela- 
tive to  the  combinations  of  treatment  employed 
showed  some  interesting  facts.  Of  the  26  patients 
in  whom  vaccines  alone  were  used,  six  have  ap- 
parently recovered,  I  1  have  improved  and  five 
showed  no  improvement.  In  8  patients  in  whom 
lavage  of  the  pelvis  alone  was  used  by  any  of 
the  above-mentioned  solutions  two  recovered,  two 
improved  and  four  remained  stationary.''^  Urinary 
cuitiseptics  used  alone  in  3 1  cases  caused  four  ap- 
parent recoveries,  thirteen  improvements  and  nine- 
teen cases  unimproved.  With  the  combination  of 
vaccine  and  pelvic  lavage,  only  two  patients  re- 
covered, t\venty  improved  and  nine  did  not  improve. 
Thirty-one  patients  in  all  were  so  treated.  Vac- 
cines and  urinary  antiseptics  in  nineteen  patients 
showed  six  recoveries,  eight  improvements  and  five 
unimproved.  Eight  patients  in  whom  vaccine,  lav- 
age and  urinary  antiseptics  all  were  used  showed 
two  recoveries,  four  improvements  and  two  non- 
improved.  Eight  patients  received  no  treatment, 
three  of  whom  apparently  recovered,  two  improved 
and  three  remained  stationary.  Seven  patients  were 
operated  on,  four  showed  surgical  lesions  in  the 
urinary  tract;  two  recovered  completely  and  five 
improved.  The  tabulated  results  of  treatment  are 
as  follows: 

Recov-   Im-      Station- 
Method    of    TreatmerJ  ered  proved       ary      Died 

Autogenous    vaccine    only 6  II  5  • — 

Pelvic   lavage  only 2  2  4  — 

Urinary    antiseptics    only 4  13  19  — 

V'accines   and    Lavage 2  20  9  — 

Vaccine  and  urinary  antiseptics.  .6  8  5  — 
Lavage  and  urinary  antiseptics.  .  .  0  I  I  — 
Vaccine,  lavage  and  urinary  anti- 
septics   2  4  2 

Bladder    lavage    only I  —  —  — 

No    treatment    3  2  3  — 

Surgery 2  4  I  — 

Death  from  renal   insufficiency.  .  .  —  —  —  4 

Death   from  other  causes —  —  —  4 

It  will  be  noted  in  the  above  tabulation  that  the 
greatest  percentage  of  recoveries  is  found  in  the 
"Vaccine  only"  column.  The  patients  who  had 
this  treatment  and  had  no  lavage  of  the  pelves  had 
very  mild  infections.  Many  of  them  showed  a 
small  amount  of  pus  in  the  urine  and  cultures  were 
obtained  only  after  repeated  trials.  These  patients 
would  probably  have  recovered  without  treatment. 

The  rather  large  group  of  patients  who  received 
antiseptics  only  were  advised  to  have  either  pelvic 
lavage  or  vaccine,  but  as  this  treatment  is  some- 
what troublesome  and  could  not  be  obtained  at 
their  homes  they  continued  the  medicine  by  mouth 
only. 

Where   lavage  was   used,   the   number   of  com- 


*Silver    nitrate    was    used    in   over   90   per    cent,    of    cases 
where  lavage  was  practiced. 


plete  recoveries  is  small.  These  cases  have  not  been 
considered  free  from  infection  until  the  urine  was 
free  from  microscopic  pus  and  until  repeated  cul- 
tures were  negative.  As  most  of  our  cases  were 
irrigated  with  silver  nitrate,  pus  could  be  obtained 
at  any  time,  but  cultures  were  repeatedly  negative 
after  the  treatment  had  progressed  for  varying 
lengths  of  time.  It  is  probable  that  the  silver  ni- 
trate was  the  cause  of  microscopic  pus  in  many 
cases  in  this  group  and  that  as  many  of  them  were 
culturally  free  from  organism  they  should  be  con- 
sidered temporarily  cured. 

f 

Conclusions. 

1 .  Infections  elsewhere  in  the  body  are  pre- 
disposing factors  in  infections  of  the  kidney  and 
ureters. 

2.  Seventy-three  per  cent,  of  these  infections 
are  bilateral  at  the  onset  of  the  disease.  The  lack 
of  pus  or  bacterial  growth  of  the  catheterized  urine 
does  not  always  mean  non-infection,  but  non-active 
infection. 

3.  Pyelography  and  guinea-pig  inoculation  may 
be  necessary  to  identify  tuberculous  infection  and 
to  differentiate  the  unilateral  from  the  bilateral  in- 
fection. The  renal  functional  tests  were  frequently 
not  of  much  value  in  differentiation  between  the 
locations  of  the  infection. 

4.  Very  careful  technic  should  be  followed  in 
obtaining  specimens  for  culture  as  contaminations 
frequently  occur  and  negate  the  bacteriologic  find- 
ings. 

5.  Treatment  affords  relief  or  cure  in  64  per 
cent,  of  cases  and  should  always  be  carried  out 
in  some  form.  No  single  method  will  give  results  in 
every  case,  so  that  all  methods  should  be  tried. 
Pelvic  lavage  has  probably  been  the  most  satis- 
factory but  whenever  possible  should  be  used  in 
conjunction  with  an  autogenous  vaccine.  Nephrec- 
tomy, when  necessary,  affords  complete  recovery 
from  general  symptoms  and  improvement  or  cure  of 
the  infection  in  the  remaining  kidney. 

REFERENCES. 

1.  Brewer,  G.  E. :  Hematogenous  Infections  of  the  Kid- 
ney, a  Summary  of  Our  Present  Knowledge.  A^en'  Yorl( 
Med.  Jour.,  1915,  CI,  556-60. 

2.  Sweet,  J.  E.  and  Stewart,  L.  F.:  The  Ascending 
Infection  of  the  Kidneys.  Surg.,  C^nec.  and  Obslel.,  1914, 
XVIII,  460-69. 

3.  Cabot,  H.:  Abstract  of  Discussion  of  Paper  by 
Cunningham,  J.  H.:  Acute  Unilateral  Hematogenous  In- 
fections of  the  kidney.  Jour.  Am.  Med.  Assn.,  1915, 
LXIV,  237. 

4.  Rosenow,  E.  C:  Transmutations  Within  the  Strepto- 
coccus-Pneumococcus  Group.  Jour.  Infect.  Dis.,  1914, 
XIV,  1-32.  Elective  Localization  of  Streptococci.  Jour. 
Am.  Med.  Assn.,    1915,   LXV. 


72 


TREATMENT  OF  NON-TUBERCULOUS 

INFLAMMATIONS  OF  THE 

SEMINAL  DUCT.* 

By   R.   \V.   Staley,   M.   D.,  Cincinnati,   Ohio, 

Inslriicior    in    Cenito-Urinar^    Surgery,    University    of 
Cincinnati. 

The  treatment  of  acute  epididymitis  has  in  recent 
years  received  considerable  attention,  and  particu- 
larly so  in  reference  to  its  surgical  aspects.  Some 
enthusiasts  would,  if  they  could  obtain  permission, 
incise  every  inflamed  epididymis,  be  it  ever  so  slight- 
ly involved,  while  others  of  an  extremely  conserva- 
tive turn  of  mind  would  never  consider  operative 
interference  at  all,  even  in  the  fulminating  cases 
where  there  is  great  swelling  and  much  pain.  There 
can  be  no  question  that  many  of  the  mild  cases  will 
resolve  fairly  promptly,  and  not  greatly  incon- 
venience the  patient  when  treated  by  our  old  pallia- 
tive measures ;  but  one  should  have  an  open  mind 
and  be  ready  to  recognize  those  cases  in  which  such 
procrastmation  will  prolong  the  patient's  suffering, 
and  possibly  lead  to  other  sequelae  unless  the  pus 
be  evacuated. 

Epididymotomy  is  such  a  simple  little  operation 
that  it  seems  ridiculous  to  have  to  make  a  plea  for 
its  recognition ;  nevertheless,  there  are  not  a  few 
genito-urinary  operators  who  have  never  tried  the 
procedure  and  who  are  skeptical  as  to  its  merits. 
It  can  be  done  in  the  office  or  dispensary  under  local 
anesthesia,  the  patient  going  home  immediately  after- 
ward. In  our  experience  the  relief  from  pain  has 
been  most  prompt  even  in  those  cases  where  the 
punctures  brought  forth  no  pus.  Resolution  has 
invariably  taken  place  more  rapidly  than  with  the 
old  expectant  routine.  Where  the  multiple  punc- 
tures into  the  epididymis  are  made  through  a  short 
scrotal  incision,  no  sutures  will  be  required.  A  com- 
fortably fitting  suspensory  or  athletic  supporter 
serves  admirably  in  retaining  the  dressings. 

In  order  to  avoid  the  open  incision,  it  has  been 
proposed  to  aspirate  through  a  needle  plunged  into 
the  inflamed  organ. 

It  is  difficult  to  understand  just  how  these  needle 
punctures  can  satisfactorily  evacuate  the  pus  in  the 
epididymis  itself,  though  it  is  conceivable  that  drain- 
age of  the  hydrocele  which  is  usually  present,  by 
lessening  the  tension,  will  give  relief  of  pain.  The 
reasonable  position  to  take  is,  that  if  an  epididymi- 
tis is  severe  enough  to  justify  any  operative  attempts, 
the  most  surgical  one  should  be  employed. 

Though  experience  has  taught  us  that  urethral 
treatment  is  best  omitted  during  the  course  of  an 
acute  epididymitis,  theoretically  it  would  seem  that 
we  are  losing  valuable  time  in  so  doing.      Several 


*Read     before     the     American     Urological    Association, 
North    Central    Section,    Chicago,    November    13th,    1915. 


[Reprinted    from    THE    UROLOGTC    AND    CUTANE- 
OUS REVIEW,   March,    1916.] 


73 


cases  having  epidymal  involvement  were  allowed  to 
continue  their  urethral  injections,  and  although  there 
was  no  extension  of  the  disease  to  the  other  epididy- 
mis in  a  single  instance,  it  was  quite  evident  that 
the  whole  process  was  prolonged. 

There  is  a  type  of  relapsing  epididymitis  which 
I  believe  is  due  to  a  focus  resident  in  the  epididymis, 
and  is  not  dependent  upon  prostatic,  vesicle  or  pos- 
terior urethral  infection.  1  he  usual  history  of  these 
cases  is  that  after  some  exertion,  trauma  or  prolong- 
ed sexual  excitement,  the  epididymis  is  tender  to 
touch,  then  gradually  begins  to  swell.  There  is 
never  so  much  swelling,  nor  is  the  pain  as  acute  as 
in  the  ordinary  form  of  the  disease  resulting  from 
extension  of  urethral  infection.  The  urine  may  re- 
main clear  all  through  the  attack,  while  the  symp- 
toms of  frequent  and  urgent  urination  are  usually 
entirely  absent.  That  these  cases  are  not  tubercu- 
lous seems  a  logical  assumption  because  they  never 
break  down  and  form  fistulae,  and  are  always  nega- 
tive to  tuberculin  tests. 

The  only  treatment  which  can  be  depended  upon 
to  be  successful  is  total  extirpation  of  the  affected 
epididymis.  As  it  is  most  likely  that  the  repeated 
inflammatory  attacks  have  obliterated  the  lumen  of 
the  vas  and  brought  about  a  one-sided  sterility,  the 
patient  will  suffer  no  great  loss  from  the  operation. 

Acute  deferentitis  is  always  preceded  by  pos- 
terior urethral,  prostatic  or  vesicle  inflammation  and 
usually  terminates  in  epididymal  involvement. 
Proper  treatment  of  the  more  important  localiza- 
tions, together  with  hot  applications  over  the  pain- 
ful cord  are  to  be  depended  upon  to  make  this  a 
trcuisitory  affection,  and  one  which  rarely  calls  for 
the  knife  in  its  management.  When  abscess  for- 
mation does  take  place,  however,  it  should  be 
promptly  opened  and  drained  in  order  to  prevent 
extension  into  the  peritoneal  cavity. 

It  is  impossible  to  consider  the  treatment  of  in- 
flammatory processes  in  the  seminal  vesicles  apart 
from  like  conditions  in  the  prostate.  Where  the 
vesicles  are  involved  the  prostate  is  surely  likewise 
affected  even  though  it  be  to  so  slight  a  degree  that 
the  examining  finger  is  unable  to  detect  anything 
abnormal. 

There  can  be  no  question  but  that  the  inaccessi- 
bility of  these  organs  has  militated  against  the  more 
frequent  employment  of  surgical  measures  in  the 
acute  conditions  to  which  they  are  subject.  Upon 
the  whole  this  has  been  a  good  thing  for  our  pa- 
tients' welfare  as  it  has  deterred  many  of  us  from 
attempting  measures  which  could  only  end  m  dis- 
appointment. Imagine  the  absurdity  of  trying  to 
drain  the  prostate  in  a  case  of  follicular  prostatitis. 
1  he  whole  gland  would  have  to  be  riddled  in  order 
to  reach  the  many  small  foci.  In  acute  seminal 
vesiculitis  early  incision  and  drainage  might  be  pro- 
ductive of  good  results  if  it  could  be  done  easily. 
However,  as  both  prostatotomy  and  vesiculotomy 
are  operations  of  some  magnitude  most  of  us  will 


content  ourselves  with  palliative  measures  in  the  mild 
or  moderately  severe  cases,  reserving  surgery  for 
those  in  w^hom  well  defined  abscess  can  be  made 
out  by  the  examining  finger,  or  the  persistence  of 
grave  constitutional  symptoms  makes  it  imperative 
that  something  be  done  to  liberate  the  suppurating 
focus. 

Either  Fuller's  incision  or  the  open  perineal  dis- 
section as  done  by  Young  and  Squier  will  be  neces- 
sary in  order  to  reach  the  vesicles,  but  a  less  ex- 
tensive operation  will  suffice  in  dealing  with  pros- 
tatic abscess.  A  slight  modification  of  lateral  lith- 
otomy in  which  the  incision  instead  of  opening  the 
urethra  goes  into  the  corresponding  lobe  of  the  pros- 
tate, is  a  method  to  be  recommended.  The  unsur- 
gical  method  of  opening  these  abscesses  through  the 
rectum  should  never  be  practiced  because  of  the 
liability  of  establishing  urethro-rectal  or  vesico-rec- 
tal  fistulae. 

The  non-operative  treatment  of  acute  prostato- 
vesiculitis  that  has  proven  itself  of  great  service  is 
heat  applied  to  the  prostatic  and  vesicle  region  by 
means  of  the  psychrophore.  Rectal  irrigations 
through  the  ordinary  fountain  syringe  tube  are  not 
easily  borne  because  of  the  irritation  of  the  anus 
caused  by  the  out-going  hot  water.  Most  of  the 
patients  with  acute  conditions  in  the  prostate  and 
vesicles  are  sick  enough  to  want  to  be  in  bed,  which 
is  certainly  where  they  should  be.  High  fever 
should  be  taken  care  of  in  the  usual  manner  and 
the  diet  ought  to  be  that  of  a  patient  suffering  from 
any  acute  febrile  disturbance.  Retention  of  urine 
is  the  only  occurrence  which  calls  for  the  em.ploy- 
ment  of  urethral  instrumentation,  and  all  injections, 
even  in  the  anterior  urethra  had  best  be  omitted 
during  the  height  of  the  disease. 

Just  when  to  begin  massage  in  these  cases  is  al- 
ways difficult  of  determination.  If  we  start  too  soon 
there  is  great  danger  of  causing  an  extension  to  the 
epididymis,  or  an  acute  exacerbation  of  the  local 
condition,  while  if  delayed  too  long  valuable  time 
will  be  lost.  When  used  at  all  in  acute  cases,  the 
massage  should  be  very  gentle,  no  effort  being  made 
by  severe  manipulations  to  cause  a  flow  of  pus  from 
the  urethra.  After  the  acute  symptoms  have  sub- 
sided, massage  becomes  our  best  weapon  of  of- 
fense, more  pressure  being  exerted  at  each  treat- 
ment in  accordance  with  the  patient's  tolerance. 

It  takes  a  little  more  time  but  is  certainly  a 
source  of  satisfaction  to  perform  massage  upon  a 
bladder  containing  four  to  eight  ounces  of  some 
clear  antiseptic  fluid,  such  as  solution  of  boric  acid. 
After  the  manipulation  when  the  patient  voids  the 
bladder  contents  into  a  glass,  ocular  inspection  will 
give  fairly  accurate  data  as  to  how  much  progress 
is  being  made.  There  is  a  definite  value  to  dilata- 
tion of  the  posterior  urethra  in  the  declining  stage 
of  prostato-vesiculitis,  which  is  not  all  due  to  the 
emptying  of  the  prostatic  ducts  and  follicles,  but 
arises  from  the  freeing  of  the  ejaculatory  ducts  of 


plugs  of  detritus,  thus  promoting  better  drainage  of 
the  ampullae  and  vesicles  when  they  are  massaged. 

Irrigation  of  vas,  ampulla  and  vesicle  by  the  Bel- 
field  method  has  also  been  of  service  in  the  sub- 
acute and  declining  stages,  especially  in  those  cases 
where  great  quantities  of  inflammatory  debris  are 
expressed  at  each  massage.  Collargol,  however, 
should  not  be  used  because  of  its  tendency  to  form 
curds  when  mixed  with  pus,  which  in  this  instance 
would  defeat  the  purpose  of  the  irrigation.  It  is 
quite  a  nice  little  point  as  to  what  strength  the  anti- 
septic should  be  and  how  much  of  the  solution  to 
inject.  It  is  wise  to  start  with  mild  solutions  and 
small  quantities,  say  about  one  c.c.  of  '/g  per  cent, 
protargol  or  5  per  cent,  argyrol,  gradually  increas- 
ing both  strength  and  volume  at  each  subsequent 
injection,  always  trying  to  avoid  vesicle  cramp 
which  is  to  be  taken  as  an  indication  of  over-dis- 
tension. 

Some  operators  have  been  disappointed  in  the  re- 
sults obtained  from  this  method,  but  there  is  no 
doubt  that  the  failure  was  due  to  an  improper  selec- 
tion of  cases  and  a  lack  of  thoroughness  in  carrying 
out  the  treatment.  Any  case  severe  enough  to  war- 
rant the  use  of  this  measure  at  all,  will  certainly 
require  more  than  one  irrigation  for  we  might  as 
well  try  to  cure  a  cystitis,  or  violent  posterior  ure- 
thritis with  one  through  and  through  bladder  lavage. 

In  the  chronic  cases,  where  a  gleety  non-specific 
discharge  is  the  only  complaint,  satisfactory  pro- 
gress will  usually  be  made  under  the  routine  meas- 
ures of  dilatation,  massage  and  irrigation,  though 
it  is  rather  difficult  to  keep  these  patients  from  be- 
coming neurasthenic. 

As  a  rule,  the  type  of  vesiculitis  in  which  im- 
potence is  a  prominent  symptom  makes  very  poor 
progress  when  treated  by  massage.  In  these  cases 
the  inflammation  has  extended  beyond  the  confines 
of  the  vesicles  and  invaded  the  surrounding  struc- 
tures. This  perivesicular  sclerosis  has  a  tendency 
of  obliterating  the  lumen  of  portions  of  the  vesicles, 
so  that  massage  is  ineffective  in  expressing  the  re- 
tained secretions.  Irrigation  through  the  vas  is  like- 
wise unavailing  for  the  same  reason.  A  carefully 
performed  vesiculotomy  in  which  as  much  attention 
is  paid  to  the  perivesicular  infiltration  as  is  to  the 
intravesicular  infection,  will  sometimes  be  followed 
by  restoration  of  sexual  function.  Though  we  may 
feel  that  mere  sexual  impotence  is  an  ailment  which 
does  not  justify  surgical  interference,  many  in- 
dividuals so  afflicted  will  gladly  undergo  operation 
in  the  hope  of  relief  from  what  is  to  them  an  in- 
tolerable condition. 

Sometimes  urinary  symptoms  overshadow  the  sex- 
ual in  these  sclerosing  cases.  These  symptoms  are 
produced  by  the  efforts  of  the  detrusors  to  over- 
come the  resistance  of  the  splint-like  perivesicular 
exudate,  which  in  some  instances  extends  well  up 
under  the  trigone  and  nearly  surrounds  the  neck  of 
the  bladder.     Such  a  patient  falling  into  the  hands 

76 


of  one  uninitiated,  would  most  likely  be  classed  as 
a  prostatic  because  of  the  presence  of  something 
hard  in  the  rectum.  Any  operative  attempt  on  the 
prostate  in  a  case  of  this  type  which  does  not  take 
into  consideration  the  vesicles  as  well,  is  doomed  to 
be  a  failure.  A  thorough  drainage  and  liberation 
of  the  vesicles  from  their  surrounding  inflammatory 
investment  will  do  much  more  for  their  real  trouble 
than  will  dilatation  of  the  prostatic  urethra,  punch 
operations  or  attempts  to  remove  the  inflamed  pros- 
tate. 

The  clinical  entity  we  know  as  gonorrheal  ar- 
thritis, is  fairly  well  understood  by  the  profession 
at  large  as  being  a  systemic  manifestation  of  a 
chronic  focus  of  infection  in  the  genital  tract;  but 
in  addition  to  this  there  are  a  number  of  other  con- 
ditions whose  relationship  to  seminal  duct  disease 
is  not  so  obvious.  This  obscurity  is  doubly  diffi- 
cult to  penetrate  where  there  is  a  negative  history 
regarding  urethral  infection.  When  we  consider 
how  rarely  a  sexual  history  is  taken,  or  a  rectal  ex- 
amination of  the  male  pelvic  organs  made  by  the 
general  practitioner,  it  is  not  to  be  wondered  at  that 
the  causative  factor  in  some  cases  of  recurrent  head- 
ache, myalgia  and  neuralgia  is  entirely  overlooked. 
A  point  which  has  been  observed,  cind  is  in  a  meas- 
ure to  be  regarded  as  diagnostic,  is  that  the  joint  or 
muscle  pain,  or  the  headache  is  worse  after  the  first 
two  or  three  massage  treatments.  This  phenomenon 
most  likely  results  from  an  overdose  of  toxins  which 
has  been  thrown  into  the  system  by  the  manipula- 
tion. 

While  it  would  seem  that  surgical  attack  offers 
the  only  chance  of  relieving  these  patients  of  their 
generalized  troubles,  we  all  know  that  our  non- 
surgical measures  do  benefit  many,  so  that  in  only  a 
small  per  cent,  of  the  cases  will  it  be  necessary  to 
consider  the  advisability  of  vesiculotomy  or  vesicu- 
lectomy. We  must  keep  in  mind,  however,  that 
massage  in  these  conditions  is  merely  palliative,  and 
though  some  individuals  will  be  able  to  go  months 
without  treatment,  relapses  are  to  be  expected  from 
time  to  time  which  will  require  further  attention. 

The  various  vaccines,  bacterial  derivatives  and 
phylacogens  which  we  were  so  enthusiastically  laud- 
ing a  few  years  ago,  have  proved  disappointing  in 
such  a  large  number  of  cases  that  most  of  us  go 
about  the  use  of  these  measures  in  a  half-hearted 
manner,  not  expecting  much  in  the  way  of  beneficial 
results.  I  feel  sure  that  in  great  measure,  the  fail- 
ures have  been  due  to  the  difficulty  in  determining  the 
exact  bacteriology  of  the  infectious  processes. 

Whenever  the  question  of  operation  in  connection 
with  rheumatoid  manifestations  is  under  considera- 
tion, every  known  means  should  be  employed  to  fas- 
ten the  guilt  where  it  belongs.  It  certainly  would 
not  be  a  creditable  situation  to  be  in,  where  after  a 
prolonged  treatment  directed  against  the  genital 
tract,  running  the  gamut  of  massage,  vaccines  and 
everything  else,  finally  culminating  in  vesiculotomy, 

77 


there  were  to  be  no  relief;  while  later  on  the  with- 
drawal of  bad  teeth,  or  removal  of  infected  tonsils 
would  bring  about  a  restoration  of  the  individual's 
health. 

There  are  two  features,  which  if  seriously  con- 
sidered, will  make  it  appear  doubtful  as  to  whether 
the  total  removal  of  the  seminal  vesicles  is  ever  war- 
ranted. In  the  first  place  we  do  not  stand  upon 
very  sure  ground  in  regard  to  our  ability 
to  place  all  the  blame  upon  the  vesicles, 
for  they  may  be  a  smaller  factor  in  the 
trouble  than  the  prostate;  it  is  certain  few  surgeons 
would  care  to  attempt  the  removal  of  the  juvenile 
prostate  for  infection.  The  other  point  is  that  by 
removing  the  seminal  vesicles  we  are  sure  to  cripple 
the  individual  sexually,  which  in  the  opinion  of  the 
patient  is  about  as  serious  a  matter  as  the  condition 
we  are  trying  to  relieve.  A  properly  performed 
drainage,  however,  is  a  different  proposition,  for 
even  if  the  arthritis  is  not  benefited,  no  harm  has 
been  done. 

To  recapitulate:  Epididymotomy  represents  a 
decided  advance  in  the  treatment  of  acute  epididy- 
mitis. Dilatation,  massage  and  irrigation  will  bene- 
fit and  keep  under  control  the  vast  majority  of  cases 
where  the  pathology  is  present  as  a  prostato-vesi- 
culitis.  Irrigation  of  the  vesicle  through  the  vcis 
in  properly  selected  cases  is  curative.  Vaccines 
have  some  brilliant  successes  to  their  credit  and  not- 
withstanding the  preponderance  of  failures,  should 
still  find  a  place  in  the  therapeutics  of  these  dis- 
orders. On  account  of  the  anatomic  and  physi- 
ologic peculiarities  involved,  it  is  evident  that  those 
general  surgical  principles  which  govern  the  mein- 
agement  of  infections  in  other  organs,  are  not  equal- 
ly applicable  here,  thus  tending  to  narrow  the  opera- 
tive procedures  to  those  having  simple  drainage  as 
their  object. 

63   Groton  BIdg. 


78 


TUBERCULOSIS     OF     THE     SEMINAL 
VESICLE  AND  EPIDIDYMIS.* 

Bv  H.  W.  Plaggemever,   M.  D.,  Detioii,   Mich. 

It  IS  a  generally  accepted  fact  that  tuberculous 
infection  in  the  genito-urinary  tract  is,  as  a  rule, 
secondary  to  a  focus  of  infection  elsewhere  in  the 
body ;  in  the  major  portion  of  cases  in  the  lungs, 
intestines,  and  bones.  That  the  disease,  however, 
does  occur  primarily  in  the  genital  tract,  has  now 
been  demonstrated  by  a  number  of  observers.  In 
this  regard,  the  cases  reported  by  Crandon,  Sax- 
torph,  Krzywicki  and  others,  of  prostatic  involve- 
ment without  appreciable  tuberculous  process  in 
other  parts  of  the  body,  and  of  Wulff,  Burckhardt 
and  Koll,  in  which  the  primary  involvement  was 
evidently  in  the  prostate,  are  of  more  than  passing 
interest. 

Guisy  in  one  hundred  and  eighty-three  cases  of 
urogenital  tuberculosis  found  ten  involving  the  pros- 
tate cUid  seminal  vesicles  alone.  Scixtorph  in  a 
series  of  two  hundred  and  five  cases,  notes  nine  such 
occurrences.  In  his  classic  contribution  to  the  sub- 
ject of  genito-urinary  tuberculosis.  Walker  found 
that  the  disease  was  stated  to  be  primary  in  the 
genito-urinary  orgcUis  with  reference  to  the  whole 
body  in  fifty-two  out  of  one  hundred  and  seventy- 
four  cases.  On  the  other  hemd,  the  same  author 
found,  in  experimental  infections,  that  no  matter 
what  mode  of  infection  was  used,  the  lungs  were 
nearly  always  involved  and  usually  showed  the  most 
advanced  process. 

Regarding  the  genital  tract  as  a  separate  entity, 
the  age  instamce  is  fairly  well  distributed,  Lyons 
reporting  a  primary  infection  in  the  seminal  vesicles 
of  a  child  of  twenty  months,  and  Barney  an  epi- 
didymal  tuberculosis  in  a  baby  of  eighteen  months, 
and  in  a  man  of  seventy-three.  Generally  speaking, 
one  might  say  that  genital  tuberculosis  is  very  rare 
up  to  the  age  of  four  months,  the  percentage  grad- 
ually increasing  till  it  reaches  its  maximum  in  the 
third  and  fourth  decade.  The  comparative  infre- 
quency  in  the  pre-pubertal  period  may  doubtless  be 
explained  by  the  latent  activity  of  the  genital  duct 
at  this  time,  the  relatively  scant  blood  supply  re- 
ducing the  hazard  of  hematogenous  infection.  The 
same  explanation  may  be  offered  for  the  fact  that, 
as  yet,  no  epididymis  has  been  reported  as  tuber- 
culous in  cases  of  undescended  testis,  possibly  due 
to  the  fact  that  all  undescended  testes  are  atrophied 
to  an  extent,  and  physiologic  activity,  though  pres- 
ent, is  in  abeyance. 

In  early  life  the  disease  often  affects  both  sides, 
but  after  twelve  the  majority  of  cases  present  a 
unilateral  involvement  when  first  seen.     In  Barney's 


*Read    before     the     American     Urological    Association, 
North   Central    Section,   Chicago,    November    13th,    1915. 


[Reprinted    from    THE    UROLOGIC   AND   CUTANE- 
OUS REVIEW,   March,   1916.] 

79 


series  of  one  hundred  and  fifty-three  cases  of  epi- 
didymal  tuberculosis,  thirty-five  per  cent,  were  on 
the  right  side,  and  thirty-five  per  cent,  on  the  left, 
a  bilateral  involvement  being  present  in  only  thirty 
per  cent.,  as  against  seventy  per  cent,  unilateral. 
These  figures  shatter  the  idea,  long  held,  that  left- 
sided  epididymitis  is  the  rule,  and  right-sided  in- 
volvement the  exception. 

The  great  mass  of  evidence  presented  by  differ- 
ent observers,  points  to  the  epididymis  as  the  organ 
most  commonly  the  seat  of  infection,  primary  for 
the  genital  tract.  Cabot  says  the  word  genito- 
urinary tuberculosis  is  a  misnomer ;  that  we  should 
come  to  recognize  that  urinary  tuberculosis  is  pri- 
mary in  the  kidney  and  genital  tuberculosis  is  pri- 
mary in  the  epididymis.  In  Walker's  second  series 
of  two  hundred  and  seventy-nine  cases,  the  kidney 
was  first  involved  in  one  hundred  and  eighty-four, 
the  epididymis  in  eighty,  the  prostate  in  six,  and 
the  seminal  vesicles  in  two.  Keyes,  however,  holds 
the  view  that  "the  weight  of  evidence  goes  to  show 
that  in  memy,  if  not  all  cases,  the  prostate  or  vesicle 
is  tuberculous  before  the  epididymis  becomes  so." 
His  contention  is  based  on  the  fact  that,  "with  a 
tuberculous  epididymis,  the  prostate  is  never  nor- 
mal, and  is  sometimes  manifestly  tuberculous  to  rec- 
tal touch.  On  the  other  hand,  with  a  tuberculous 
prostate  or  vesicle,  the  epididymis  is  not  necessarily 
involved ;  also  involvement  of  the  prostate  or  vesicles, 
or  both,  precedes  involvement  of  the  second  epididy- 
mis. 

One  cannot  deny  the  verity  of  these  conditions 
from  a  clinical  standpoint.  But  there  is  also  much 
authentic  evidence  to  the  effect  that  the  epididymis 
is,  in  most  cases,  affected  first. 

Watson  in  a  series  of  twelve  cases,  found  on 
careful  examination  that  the  tuberculous  infection 
began  in  the  epididymis  of  one  side.  In  four  of 
these,  there  was  an  extension  to  the  vas  and  the 
vesicle  of  the  same  side,  without  any  evidence  that 
the  prostate  had  been  involved.  In  none  of  the 
other  eight  did  the  process  advance  beyond  the 
epididymis  or  testis,  these  patients  being  watched  for 
periods  varying  from  eight  to  twenty-three  years. 
The  same  author  claims  to  have  seen  only  three 
cases  in  which  the  disease  was  present  in  the  pros- 
tate, as  the  only  part  affected  below  the  bladder. 
In  these  the  kidney  was  thought  to  be  affected  in 
each  instance. 

This  would  seem  to  offer  evidence  that  the  dis- 
ease may  be  manifest  at  either  end  of  the  tract, 
with  an  interval  of  time  between  its  manifestation 
at  either  point,  the  kidney  or  the  epididymis.  Also 
it  is  clearly  shown  that  an  epididymal  infection  may 
follow,  chronologically  at  least,  a  renal  infection 
of  the  same  side  without  implicating  the  prostate 
or  seminal  vesicles,  and  yet  again,  that  the  process 
may  begin  in  the  epididymis  and  remain  localized 
there,  without  ever  involving  any  other  part  of  the 
tract. 

80 


The  genital  tract,  in  its  development,  bears  a 
striking  analogy  to  the  urinary  tract.  The  epididy- 
mis is  a  remnant  of  the  mesonephros,  and,  in  its 
rudimentary  excretory  capacity,  it  might  be  ex- 
pected to  pick  up  micro-organisms  from  the  circu- 
lation in  a  manner  entirely  similar  to  that  of  the 
kidney.  Theoretically,  one  might  then  look  to  the 
epididymis  as  the  primary  seat  of  invasion  for  the 
genital  tract,  as  the  kidney  is  the  recognized  primal 
site  in  the  via  urinaria.  A  striking  example  of  this  de- 
velopmental relationship  is  seen  in  the  case  cited  by 
Frisch  and  Zuckerkandl,  in  which  a  patient  had 
a  tuberculous  kidney  removed.  The  mucous  mem- 
brane of  the  ureter  and  the  trigone  of  the  bladder 
were  found  to  be  implicated  in  the  process  also. 
Several  months  later,  the  epididymis  became  tuber- 
culous without  either  the  prostate  or  seminal  vesicles 
bemg  mvolved. 

By  the  same  token,  the  prostatic  anlage  and  its 
early  functions,  being  of  such  different  nature  from 
that  of  the  epididymis,  it  is  easy  to  see  why  this 
glcUid  and  its  adnexa,  the  vesicles,  might  be  less  fre- 
quently the  seat  of  primary  infection.  And  con- 
tmuing  the  adverse  comparison  still  further,  and  by 
the  same  logic,  one  might  be  led  to  suspect  a 
priori,  that,  from  their  wide  difference  in  genesis, 
as  well  as  by  their  relative  remoteness  from  direct 
urinary  infection,  the  vesicles  would  be  less  open 
to  primary  infection  than  the  prostate,  and  this  is 
fairly  proved  to  be  the  case  by  the  best  obtainable 
statistics  in  a  proportion  of  one  to  three. 

Much  experimental  evidence  has  been  put  forth 
to  prove  the  capacity  of  normal  vesicles  to  secrete 
tubercle  bacilli.  Landouzy  and  Martin  found  in 
guinea-pigs,  that  if  the  lumenar  contents  of  the  vesi- 
cles were  taken  from  tuberculous  animals  in  which 
the  vesicles  were  not  involved,  the  material  pro- 
duced tuberculosis  when  injected  into  other  animals. 
Sirena  and  Pernice  also  found  that  they  could  pro- 
duce tuberculosis  in  the  peritoneal  cavity  of  a  dog, 
by  injecting  material  gotten  from  the  vesicles  of  in- 
dividuals dead  of  tuberculosis,  but  having  no  in- 
volvement of  the  vesicles.  Maffuci  injected  rabbits 
with  large  doses  of  tubercle  bacilli.  In  twenty-six 
days  he  discovered  the  bacilli  on  the  mucosa  of  the 
otherwise  normal  vesicles.  Nakarai,  in  a  human 
subject,  discovered  tubercle  bacilli  in  normal  vesi- 
cles. Jaechk,  Gaertner,  Cavagnis,  Albrecht,  and 
Kochel  all  conclude  that  these  organs  secrete  the 
bacilli  more  often  than  any  other  part  of  the  geni- 
tal tract. 

In  the  face  of  this  evidence  one  might  still  as- 
sume that  the  examination  of  these  organs  has  not 
been  exhaustive  enough  to  warrant  the  belief  in 
this  healthful  secretory  faculty  as  an  established 
fact,  and  it  is  extremely  probable  from  the  ex- 
perimental work  of  Walker,  that  all  vesicles  which 
secrete  tubercle  bacilli  have  a  tuberculous  focus 
somewhere  in  the  submucous  tissues,  which  is  the 
first  site  of  election.     Whether  the  normal  vesicle 

81 


can  harbor  and  then  cast  off  the  tubercle  bacillus 
with  impunity,  or  whether  its  histone  producing 
faculty  has  a  deleterious  influence  on  its  capacity  as 
host  to  that  organism,  through  its  agglutinating 
power  on  the  tubercle  bacillus,  as  in  some  of  the 
lower  animals  can,  on  the  face  of  the  evidence  of- 
fered, be  viewed  at  present,  only  as  an  unsolved 
problem.  Suffice  it  to  say,  however,  that,  though 
the  seminal  vesicle  infection  is  present  as  a  secondary 
involvement  in  about  sixty  per  cent,  of  cases  of 
tuberculosis  of  the  genital  duct,  its  primary  involve- 
ment is  in  all  probability  an  extreme  rarity,  and 
from  the  standpoint  of  its  primarity  alone,  is  not  to 
be  viewed  essentially  as  a  surgical  factor.  As  an 
academic  fact,  the  developmental  analogy  of  the 
seminal  vesicles  and  the  urinary  bladder  is  striking, 
and  our  minds  have  long  since  been  made  up  as  to 
method  of  attack  in  tuberculous  disease  of  the  lat- 
ter. One  is  quick  to  leave  the  bladder  and  to  at- 
tack the  kidney  when  it  is  definitely  known  that  the 
latter  is  involved,  and  generally  speaking,  one  might 
do  worse  than  follow  the  same  rule  in  the  case  of 
the  vesicles  and  epididymis. 

Approaching  the  field  of  controversy  as  to  local 
avenues  of  extension  in  the  genital  duct  per  se,  one 
is  faced  with  much  argument,  and  much  experi- 
mental work,  purporting  to  prove  extension  via  the 
vas  in  each  direction. 

The  work  of  Baumgarten  and  Kraemer  would 
make  it  appear  that  from  a  posterior  urethral  infec- 
tion, the  process  is  never  propagated  through  the 
vasa  deferentia  to  the  epididymis,  while  infection 
of  the  vas  or  seminal  vesicles  does  extend  to  the 
urethra,  in  fact,  that  an  advance  of  the  process 
never  takes  place  against  the  direction  of  the  sem- 
inal current.  In  a  large  number  of  cases  of  experi- 
mental tuberculosis  of  the  prostate  and  vesicles,  they 
did  not  observe  a  single  animal  in  which  the  disease 
had  extended  down  the  vas.  They  claim  that  the 
constant  stream  in  the  vas  from  below  upwards 
prevents  the  non-motile  tubercle  from  going  down, 
that  the  ciliated  epithelium  tends  also  to  prevent 
the  downward  passage  of  the  organisms,  and  that 
it  requires  too  many  days  for  them  to  multiply  in 
the  normal  secretion.  Directly  opposed  to  this  are 
the  experiments  of  Paladino-Blandini,  which  indi- 
cate that  the  tuberculous,  as  well  as  other  micro- 
organisms placed  just  within  the  external  urethral 
meatus  do  infect  the  deeper  parts  of  the  tract  by 
direct  extension  backward  along  the  urethra  and 
directly  against  the  current.  They  do  not,  how- 
ever, prove  extension  further,  through  the  vas. 

It  has  long  been  a  moot  clinical  question  as  to 
whether  local  infection  of  the  glans  takes  place 
through  coitus.  The  weight  of  authority  is  against 
this,  yet  Frank,  Schuchardt,  Tedenat,  and  Prat- 
Lacene  have  all  recorded  very  suspicious  cases,  and 
the  possibility  must  be  granted.  Garin  cites  the 
case  of  a  man  with  ulceration  of  the  glans,  fol- 
lowed by  tuberculosis  of  the  prostate,  vesicles,  and 

82 


epididymis,  and  Julius  Frank,  the  case  of  a  boy 
fourteen  years  old,  with  a  tuberculous  ulcer  of  the 
glans  followed  by  infection  of  the  epididymis.  Sev- 
eral cases  have  been  reported,  two  in  the  knowledge 
of  the  writer,  where  infection  of  the  prepuce  with 
extension  backward  has  taken  place  from  rabbis, 
known  to  be  tuberculous,  in  performing  the  ortho- 
dox rite  of  circumcision.  Neither  of  these  au- 
thors, however,  proves  that  the  deep  infection  was 
not  a  hematogenous  one. 

Teutschlander  argues  as  follows  in  favor  of  the 
descension  theory. 

( 1  )  Ciliated  epithelium  does  exist  in  the  epi- 
didymis but  not  in  the  vas. 

(2)  Primary  tuberculosis  of  the  vesicles  is  often 
overlooked,  for  the  reason  that  it  is  not  searched 
for  in  the  early  stage. 

(3)  One  should  not  draw  conclusions  from 
rabbits,  for  the  reason  that  their  vesicles  and  pros- 
tates differ  so  markedly  from  those  in  man. 

(4)  Reports  several  cases  in  the  human  in 
which  the  disease  seemed  certainly  to  have  ex- 
tended from  the  vesicles  partly  down  the  vas. 

Stonham  had  a  patient  in  whom  the  left  seminal 
vesicle  was  very  much  enlarged.  When  the  left 
vas  was  opened  the  mucosa  beginning  with  the  pros- 
tate and  extending  for  some  distance  was  studded 
with  small  tubercles  and  ulcerations.  The  disease 
ended  abruptly  and  beyond  this  point  the  vas  was 
sound  and  the  epididymis  was  normal.  This  seems 
to  be  an  instance  of  an  undoubted  extension  down 
the  tube. 

Oppenheim  and  Low  found  that  by  stimulating 
the  hypo-gastric  nerve,  they  could  produce  a  re- 
versed peristalsis  in  the  vas.  They  also  found  that 
by  stimulation  of  the  verumontanum,  they  could 
bring  about  a  similar  result.  This  they  were  led 
to  believe  held  true  for  men  as  well  as  for  rabbits 
and  guinea-pigs.  They  therefore  believe,  that,  dur- 
ing an  infection  of  the  posterior  urethra,  an  irrita- 
tion may  produce  a  reverse  peristalsis  and  set  up 
an  infection  of  the  epididymis,  by  direct  descension. 

Walker,  in  a  large  series  of  rabbits  with  tuber- 
culosis of  the  prostate  and  vesicles,  noted  one  ani- 
mal only,  in  which  he  thought  the  infection  might 
possibly  have  passed  down  the  cord.  In  two  ani- 
mals in  which  he  placed  pieces  of  tuberculous  lung 
in  the  urethra,  there  was  widespread  involvement  of 
the  vas  and  epididymis,  and  careful  examination  of 
the  specimens  made  it  appear  that  the  extension 
was  a  direct  one  down  the  vas. 

In  emother  series  of  eleven  animals,  m  which  tu- 
berculous cotton  was  inserted  in  the  seminal  vesicles, 
two  had  involvements  of  the  epididymis,  which  he 
took  for  evidence  of  downward  extension.  Of 
thirty  animals,  in  which  the  injections  were  made 
into  the  posterior  wall  of  the  bladder,  two  showed 
implication  of  the  vasa.  In  one,  the  epididymis 
was  also  affected.  In  the  other,  the  tvhole  right 
vas  and  part  of  the  globus  minor  rvere  affected; 

83 


on  the  other  side  the  vas  was  uniformly  diseased. 
The  above  instances  by  a  most  careful  observer, 
F>oint  very  strongly  to  the  conclusion  that  the  dis- 
ease ma^  descend. 

However,  the  same  author  noted  in  his  experi- 
ments, the  great  frequency  and  ease  with  which 
the  disease  spreads  from  below  upwards,  and  the 
relative  infrequency  and  difficulty  with  which  in- 
fection descends. 

As  to  the  method  by  which  the  diseeise  passes 
from  the  epididymis  upwards,  it  is  asserted  by 
Baumgarten  that  the  bacilli  are  carried  upward 
by  the  stream  of  the  vas.  To  this  theory  the  follow- 
ing objections  may  be  raised: 

( 1  )  Tuberculosis  in  many  instances  affects  the 
vas  to  such  a  degree  that  the  lumen  in  the  lower 
part  is  entirely  occluded  and  often  obliterated  be- 
fore the  upper  part  is  involved. 

(2)  When  the  vas  is  ligatured  in  animals,  the 
infection  is  delayed,  but  later  the  disease  passes  on 
above. 

(3)  Again,  if  the  force  of  the  vas  stream  were 
strong  enough,  there  would  be  implantation  generally 
and  simultaneously  along  the  epithelium  lining  the 
lumen. 

It  is  possible  that  ascension  by  the  subepithelial 
lymphatics  would  explain  this. 

Baumgarten  and  his  pupils  are  probably  right 
in  the  main,  but  that  they  go  too  far  in  asserting 
that  descending  infection  never  takes  place,  the 
work  of  Walker  would  show. 

How  else  could  one  explain  a  tuberculosis  of 
the  vesicles  or  prostate  and  a  continuous  involve- 
ment of  the  adjoining  vas,  with  a  free  epididymis 
and  testis.  If  it  were  not  direct  infection,  it  must 
be  through  the  lymphatics  or  the  blood  stream,  in 
which  case,  one  would  certainly  expect  involvement 
of  the  epididymis  or  testicle,  or  both. 

Ascension  certainly  seems  to  be  the  rule;  de- 
scension  the  exception. 

All  that  can  be  actually  postulated  as  to  the 
peripatetic  activity  of  the  tubercle  bacillus  is  that 
it  enters,  in  the  great  majority  of  cases,  by  way  of 
the  kidney  into  the  urinary  tract,  and  descends 
by  preference,  and  mounts  from  below  with  reluct- 
ance, if  at  all,  and  then  most  probably  by  the 
lymphatics.  The  large  proportion  of  cases  in  which 
the  epididymis  or  testicle  when  involved,  appear 
clinically  to  be  the  first  seat  of  tuberculous  lesion 
in  the  genito-urinary  tract,  and  the  relatively  greater 
proportion  for  the  genital  tract  alone,  as  well  as  the 
frequency  with  which  the  disease  apparently  re- 
mains limited  to  these  structures,  points  strongly  to 
the  blood  current,  or  the  lymph  tract,  as  the  usual 
path  of  approach.  This  evidence  is  augmented  by 
the  large  number  of  recorded  cases  in  which  the 
foci  were  sub-epithelial  or  intertubular.  A  further 
verification  of  this  premise  is  found  in  the  fre- 
quency with  which  the  globus  major  is  attacked  in 
unilateral  cases,   or  in  which,   if  a  wider  area  be 

84 


involved,  the  upper  portion  of  the  epididymis  is 
evidently  the  site  of  the  first  involvement,  with  or 
without  involvement  of  the  upper  pyole  of  the  testis. 
This  condition  when  present  without  complication, 
is  practically  always  primary,  and  is  considered  by 
many,  a  diagnostic  point,  though  Koll  has  recently 
shown  that  in  other  infections,  such  as  colon,  staphy- 
lococcus, streptococcus,  etc.,  the  clinical  manifesta- 
tion may  be  so  similar,  that  only  careful  study  of 
the  removed  epididymis  will  tell  the  story. 

To  further  confuse  the  time-honored  clinical  pic- 
ture. Walker's  injection  of  the  aorta  with  tubercle 
bacilli  in  twenty-eight  animals  gave  the  following 
results :  Eight  showed  tuberculous  epididymitis ; 
five  on  the  left,  three  on  the  right ;  in  four  the 
globus  minor  was  affected;  in  two  the  globus  major. 
This  would  point  to  the  globus  minor  as  the  more 
common  locus  of  hematogenous  infection,  and  is  at 
variance  with  the  clinical  observations  of  others. 

The  involvement  of  the  second  side  usually  oc- 
curs as  in  gonococcal  infection,  in  the  globus  minor, 
most  often  with  fulminating  symptoms,  suggesting 
mixed  infection.  It  would  seem  then,  that  in  many 
cases,  when  the  second  side  becomes  involved,  the 
disease  has  traveled  up  and  involved  the  prostate 
and  seminal  vesicles,  and  then  gone  dorvn  the  vas, 
just  as  in  Nelsserian  infection.  This  is  clinical  evi- 
dence in  favor  of  the  descension  theory,  by  way  of 
the  lumen  of  the  vas. 

To  recapitulate;  massive  infection  can  pass  in 
either  direction  in  the  vas  by  continuity,  but  direct 
conduction  by  the  lumen  is  rare,  and  if  accom- 
plished is  negative  in  its  effect  on  normal  epithelium. 
Descending  infection  from  all  parts  to  the  genital 
tract  is  in  most  instances  via  the  blood  stream,  and 
ascending  infection  to  other  parts  of  the  genital 
tract  by  way  of  the  lymphatics,  an  infected  vesicle 
on  the  opposite  side  to  the  primarily  infected  epididy- 
mis being  explained  by  the  decussation  of  the  lymph 
paths  at  the  base  of  the  bladder. 

Treatment. — One  must  frankly  confess  at  the 
outset,  that  there  is  no  subject  in  the  range  of  sur- 
gical diseases  of  the  genito-urinary  tract  about  which 
there  is  so  much  diversity  of  opinion  among  compe- 
tent observers  as  in  tuberculosis  of  the  seminal  vesi- 
cles and  epididymis.  The  expressions  of  opinion 
gotten  through  personal  correspondence  with  the 
leading  clinics  and  sanatoriums  of  the  country  are 
conflicting,  but  the  composite  result  may  be  summed 
up  briefly  as  follows : — 

When  tuberculosis  involves  the  epididymis  alone, 
epididymectomy  should  be  performed ;  this,  in  face 
of  the  argument  advanced  by  some  that  operative 
interference  may  cause  a  flare  up  on  the  opposite 
side.  The  march  is  rapid  without  operation.  In 
the  last  series  reported  from  the  Massachusetts 
General  Hospital,  of  thirty-three  unoperated  epi- 
didymes  eighteen  or  fifty-five  per  cent,  became  in- 
volved on  the  opposite  side  within  a  year  after  in- 
vasion of  the  first  side. 


If  both  epididymes  are  involved,  double  epididy- 
mectomy  is  indicated,  for  this  operation  does  not 
impair  masculinity  and  sterility  has  in  most  cases 
already  taken  place,  even  before  the  second  side 
was  involved. 

Knowfing  that  invasion  of  the  second  testicle  is 
likely  in  either  case,  and  recognizing  the  great  value 
of  the  testicular  hormone,  it  is  questionable  whether 
orchidectomy  is  ever  indicated.  Some  of  the  re- 
ported results  of  subsidence  of  activity  in  this  gland 
following  epididymectomy  are  little  short  of  mar- 
velous, and  when  it  is  mechanically  possible  to  re- 
move the  epididymis  and  still  leave  the  testicle  some 
blood  supply,  it  is  safe  to  hope  that,  except  in  rare 
instances,  the  latter  can  be  saved.  In  none  of 
Barney's  cases  did  the  patient  return  for  subse- 
quent orchidectomy  and  Keyes  reports  one  case 
only,  and  that  as  a  rarity.  When  both  epididymis 
and  testicle  are  involved,  it  is  better  to  incise  and 
drain,  if  pus  is  present.  In  regard  to  the  removal 
of  the  vas,  if  the  latter  is  involved  massively  in  its 
entire  extent,  the  high  operation  of  Cabot  is  the 
procedure  of  choice,  but  the  advisability  of  this 
method  as  a  routine  procedure  is  open  to  question. 
It  is  doubtful  if  the  opening  of  the  tissues  will  in 
any  way  benefit  the  further  development  of  a  tuber- 
culous peritonitis,  if  such  a  condition  has  already 
supervened. 

In  the  experience  of  many  active  workers  in  this 
field,  the  removal  of  the  epididymis  and  contiguous 
portion  of  the  vas  has  had  a  most  signal  effect  on 
the  process  in  the  vesicles;  the  infection  has  re- 
ceded, and  the  vesicles  have  become  fibrous.  Re- 
cently Young  has  been  advocating  vesiculectomy 
under  certain  conditions.  The  operation  is  a  diffi- 
cult one,  and  two  of  the  largest  clinics  of  the  country 
have  each  noted  four  cases  of  impotence  following 
the  operation.  These  reports  are  as  yet  unpublished. 
Still  in  the  type  of  cases  selected  by  Young,  where 
the  disease  is  limited  entirely  to  these  glands  and 
does  not  involve  the  prostate,  vesiculectomy  is  un- 
questionably a  splendid  operation,  because  it  re- 
moves entirely  the  focus  of  disease.  On  the  other 
hand,  if  the  prostate  be  involved,  vesiculectomy 
should  not  be  performed,  as  the  chance  of  persistent 
perineal  fistula  is  too  great.  This  may  appear  as 
too  conservative  to  those  in  favor  of  radical  re- 
moval of  all  caseous  foci,  but  considering  the  type 
of  disease  with  which  we  are  dealing,  it  is  prob- 
ably better  to  err  on  the  side  of  caution,  especially 
where  the  lower  duct  is  first  involved.  For  as  has 
been  noted,  the  removal  of  the  first  part  involved 
in  a  large  number  of  instances,  causes  recession  of 
the  process  in  the  higher  parts  which  are  so  fre- 
quently the  victims  of  a  secondary  invasion. 

The  prognosis  in  primary  tuberculosis  of  the 
genitals  in  children  is  usually  good.  In  fact  there 
seems  to  be  a  limitation  of  the  tuberculous  process 
in  all  organs  of  children,  the  one  notable  exception, 
of  course,  being  the  meninges.    This  tendency  to  lo- 

86 


calization  in  the  pre-pubertal  period  in  contra-distinc- 
tion  to  the  wider  involvement  usually  encountered 
in  later  periods  of  life  is  a  strong  argument  for 
radical  operation  with  a  view  to  permanent  cure. 

Too  much  emphasis  cannot  be  laid  on  the  value 
of  hygienic  and  climatic  treatment,  both  pre-opera- 
tive  and  post-operative,  especially  the  use  of  helio- 
therapy as  advocated  by  Lawrason  Brown,  for  it 
must  be  kept  in  mind  that  in  the  larger  percentage 
of  cases  we  are  dealing  with  more  or  less  generalized 
tuberculosis  in  other  parts  of  the  body.  The  writer 
is  in  favor  of  Corbus'  idea  of  active  immunization 
before  operation  by  producing,  in  maximal  amounts, 
antibodies  to  all  constituents  of  the  tubercle  bacillus, 
it  being  understood  that  the  patient  has  no  closed 
foci  from  which  absorption  is  taking  place  and  is  not 
already  supplied  with  an  excessive  amount  of  anti- 
gen. 

Ultimate  Results. — Of  the  one  hundred  and 
thirteen  cases  followed  at  the  Massachusetts  Gen- 
eral Hospital,  twenty-seven  per  cent,  have  died  of 
some  form  of  tuberculosis.  Of  these  deaths,  four- 
teen per  cent,  occurred  within  one  month,  thirty- 
two  per  cent,  within  six  months  and  fifty  per  cent, 
within  one  year  after  operation.  During  the  first 
six  years,  eighty-five  per  cent,  died,  while  between 
the  ninth  and  eleventh  years  10.7  per  cent,  suc- 
cumbed. Miliary,  renal  and  lung  involvement  are, 
in  order,  the  final  types  of  the  disease.  The  con- 
clusion reached  in  this  report  is  that  until  at  least 
ten  years  have  elapsed  after  operation,  no  patient 
can  be  said  to  be  cured  of  tuberculosis. 

In  conclusion,  genital  tuberculosis  in  the  male  is 
a  very  grave  affection,  and  except  in  the  case  of 
children,  where  the  local  process  often  remains  the 
only  tuberculous  focus  in  the  body,  operation  is  only 
to  be  looked  on  as  one  of  the  means  to  an  end,  and 
conservative  effort  is  to  be  looked  upon  with  favor. 
The  survival  of  the  patient,  primary  foci  being  re- 
moved, depends  largely  on  the  ability  of  his  body  to 
immunize  itself  to  the  disease,  to  the  development 
of  which  immunity  our  chief  efforts  should  be  di- 
rected. 

BIBLIOGRAPHY 

Anshutz,  W.:  Tuberculosis  of  the  Epididymis.  Medizin- 
ische  KUnik.  Jan.  4,    1914,  Vol.  X    (Abstr.). 

Barney,  J.  Delinger:  Tubercular  Epididymitis;  End  Re- 
sults of  71  Cases.  Boston  Medical  and  Surgical  Jour.,  Vol. 
CLXVI,  Noll.  pp.  409-414.  March   14,   1912. 

Barney,  J.  Delinger:  Observations  on  the  Seminal  Ves- 
icles.     Interstate  Medical  Jour.,   Vol.  XXI,   No.    11,    1914. 

Barney,  J.  Delinger:  The  Value  of  the  Guinea-Pig 
Test  in  Genito-Urinary  Tuberculosis.  Boston  Medical  and 
Surgical  Jour.,  Vol.  CLXIV,  No.  26,  pp.  917-919,  June, 
29,  1911. 

Barney,  J.  Delinger:  Recent  Studies  in  the  Pathology 
of    the    Seminal    Vesicles.      Boston    Medical    and    Surgical 

Jour.,  Vol.  CLXXI,  No.  2,  pp.  59-62,  July,  9,   1914. 

Barney,  J.  Delinger:  The  Ultimate  Results  of  Genital 
Tuberculosis  in  the  Male.  Transactions  A.  M.  A.  Genito- 
Urinary   Section.      1914. 

Barney,  J.  Delinger:  Tuberculosis  of  the  Epididymis 
and    Prostate.      Boston    Medical    and    Surgical    Jour.,    Vol. 

CLXVI  I.   No.  25,  pp.  923-927.  June   19.   1913. 
87 


Barney,  J.  Delinger:  Tubercular  Epididymitis;  An 
Analysis  of  153  Cases.  American  Jour,  of  Urology^,  De- 
cember,   1911. 

Baumgarten,  P.  and  Kraemer,  C. :  Experimentelle 
Studien  iiber  Hislogenese  und  Ausbreitung  der  Urogenital 
Tuberculose.  Arb.  a.  d.  Ceb.  d.  Path.  Anal.  Inst.  zl» 
Tubingen,    1902-3,   IV,    173-198. 

Burclchardf:    Muench.  med.Woch.,  1911,  p.  1750. 

Corbus,  B.  C. :  Immunization  in  Genito-Urinary  Tuber- 
culosis: A  Procedure  of  Immunization  Before  Operation. 
Transactions  American  Urological  Assoc.  Philadelphia, 
1914. 

Crandon,  L.  R.  G. :  Tuberculosis  of  the  Prostate.  Bos- 
ton M.  and  S.  /.,   1902,  CXLVII.  17-19. 

Frank,  J.:  Uber  Tuberculose  des  Penis.  Inaug.  Diss. 
Strassburg,   1897. 

Fuller,  Eugene:  Surgery  of  the  Seminal  Vesicles.  Med- 
ical Record.,  Jan.  23,    1915. 

Fuller,  Eugene:  Seminal  Vesiculotomy:  Its  Purpose 
and  Accomplishments.  Medical  Record,  New  York,  Oct. 
30,  1909. 

Garin,  J.:  Observation  de  Tuberculose  des  organes 
genito-urinaires.  Mem.  et  compt-rend.  Soc.  d.  sc.  Med. 
de  Lyons,  1877,  XVI,  pt.  2,  36-40. 

Goodman,  A.  L. :  Tuberculosis  of  the  Testicle.  Med- 
ical Record,  Jan.  24.    1914,   Vol.   85. 

Guisy,  B.:  Tuberculose  prostatovesiculaire.  Revue  in- 
ternal, de  la   tuberc,    1906,  X,  81-87. 

Hesse,  F.  A.:  Tuberculose  der  Prostate.  Berliner  k^in. 
Wochenschrift,  June  22,    1914.  Vol.  51. 

Keyes,  E.  L.,  Jr.:  Diseases  of  the  Genlto-Urinary 
Organs.     Text-book,  pp.  475-478. 

Keyes,  E.  L.,  Jr.:  Tuberculosis  of  the  Testicle:  Ob- 
servations Upon  100  Patients.  .Annals  Surg.,  Phila.,  1907, 
XIV.  918. 

Koll.  I.  S.:  Primary  Tuberculosis  of  the  Prostate  Gland. 
Annals  of  Surgery,  Vol.  LXII,  No,  4,  October,  1915,  p. 
473. 

Kraske,  P.:  Ueber  einen  Fall  von  tuberkuloser 
Erkrankungen  der  Glans  penis,  etc.  Beilr.  z.  path.  Anat. 
u.  z.  allg.  Path.,  Jena.  1891.  X.  204-210. 

Krzywicki,  C.  V.:  29  Falle  von  Urogenital-tubercnlose 
darunter  ein  Fall  von  Tuberculose  beider  Ovarien.  Zeigler's 
Beitrage,  1888,  III,  297. 

Landouzy,  L.:  Et  Martin  H.  Faits  cliniques  et  ex- 
perimentaux  pour  servir  a  I'histoire  de  I'heridite  de  la 
tuberculose.     Revue  de  med.,  1883,  III,   1014,   1032. 

Lewis,  Bransford:  Urogenital  Tuberculosis.  Buffalo 
Medical  Jour.,  July.    1909.   pp.  643-56. 

Lindmann:  Ein  Beitrag  zur  Frage  von  der  Conta- 
giositat  der  Tuberculose.  Deutsch.  med.  Wchnschr.,  1883, 
IX,  442. 

Lyons,  O.:     A.  M.  A.  Trans.,   1914. 
Marinisco,    R.:      Epididymectomy   for   Tuberculosis. 
Martin,    A.    M.:      Tuberculosis    Disease   of    Epididymis, 
Vas,  and  Seminal  Vesicles;   Removal  in  One  Piece.  North- 
umberland   and   Durham,    M.    J.,    New-Castle-Upon-Tyne, 
1903,  XI,  169-173. 

Nakarai,  S. :  Experimentelle  Untersuchungen  uber  das 
Vorkommen  von  Tuberkelbazillen  in  den  gesunden  Genitai- 
organen  von  Phthisikin.  Beitrage  z.  path.  Anat.  v.  z.  allg. 
Path.,  1898,  XXIV,  327-342. 

Oppenheim,  M.  w  Low  O.:  Klinische  und  experimen- 
talle  Studien  zur  Pathogenese  der  gonorrhoischen  Epididy- 
mitis.    Virchow's  Archiv.,  1905,  CLXXXII. 

Paladino-Blandini:  Cuyons  Annals,  1900,  XVIII. 
1009. 

Saxtorph,  S.:  Valeur  de  I'intervention  chirurgicale  dans 
la  tuberculose  vesicle.  Comp.  rend.  13  congr.  internat.  de. 
med.,  Paris,   1900,  97. 

Simmonds,  J.:  Tuberculosis  of  the  Male  Genital  Sys- 
tem. Beitrage  z.  Klinilf  d.  Tuberculose.  November.  1914, 
Vol.  XXXIII    (Abstr.). 

Stonham,  C.:  Tubercular  Disease  of  the  Left  Vesi- 
cula  Seminalis  and  Left  Half  of   the   Prostate  with   Exten- 

88 


sion  into  the  Left  Vas  Deferens.     Trans.  Path.  Soc,  London, 

1887-8.    XXXIX.   197. 

Teutschlander,  O.  R. :  Wie  breitet  sich  die  genital- 
luberculose  aus?  (Ascension  und  Descension.)  Dcitr.  z. 
klin.  d.  iuberk.,    1906.  Vol.  V.  83-182. 

Thomas.  B.  A.  and  Pancoast,  H.  K. :  Observations  on 
the  Pathology,  Diagnosis  and  Treatment  of  Seminal  Vesicu- 
litis. Annals  of  5urgerji.  September,  1914.  Vol.  XXXVII, 
No.  5,  pp.  313-318. 

Uchimura,  M.:  Tuberculosis  Disease  of  the  Genito- 
Urmary  Organs,  as  Seen  on  Post-Mortem  Lxamination, 
Sei-i-Kii>ai  Medical  Jour.,  Vol.  XXXIII,  May  10. 
(Abstr.) 

Voelcker.  F.:  Excision  Tuberculoser  Samenblasen  mit 
temporarer  Verlagerung  des  Rectum.  Beitr.  z.  t(Un.  Chir., 
Tubing.    1911.  LXXII.  722-740. 

Walker.  George:  The  Nature  of  the  Secretion  of  the 
Vesiculae  Seminales  and  of  an  Adjacent  Glandular  Struc- 
ture in  the  Rat  and  Guinea-Pig  with  Especial  Reference 
to  the  Occurrence  of  Histone  in  the  Former.  Johns  Hop- 
kins' Hospital   Bulletin,    Vol.   XXI,    No.   231,   June.    1910. 

Walker,  George:  A  Special  Function  Discovered  in  a 
Glandular  Structure  Hitherto  Supposed  to  Form  a  Part  of 
the  Prostate  Gland  in  Rats  and  Guinea-Pigs.  Ibid.,  Vol. 
XXI.  No.  231,  June,   1910. 

Walker,  George:  The  Effect  on  Breeding  of  the  Re- 
moval of  the  Prostate  Gland  or  of  the  Vesiculae  Seminales 
or  of  Both:  Together  with  Observations  on  the  Condition 
of  the  Testes  After  Such  Operations  on  White  Rats. 
Johns   Hospins'  Hospital  Reports,  Vol.   X.VI. 

Walker.  George:  Studies  in  the  Experimental  Produc- 
tion of  Tuberculosis  in  the  Genito-Urinary  Organs.  Johns 
Hopkins'   Hospital   Reports,   Vol.   XVI. 

Watson     and     Cunningham:       Genito-Urinary     Diseases. 

Vol.  II.  p.  414. 

Weisz.  Franz:  Diseases  of  the  Seminal  Vesicles.  Urol. 
AND  Cutaneous  Review,  Technical  Supplement,  p. 
243.  July.  1914. 

Wildbolz.  H.:  Tuberculosis  of  the  Urinary  Organs.  Urol. 
and  Cutaneous  Review.  Technical  Supplement,  p. 
128,  April,  1915. 

Wulff:      Deutsch.  med.   Woch.,   1909.  p.   1332. 


89 


TRANSACTIONS 

Joint    Meeting    of    the    American    Uro- 

LOGiCAL  Association  (North  Central 

Section)  With  the  Chicago  Uro- 

LOGICAL  Society. 

NOVEMBER    12  AND    13,    1915. 

The  President  of  the  Chicago  Urological  So- 
ciety,   Dr.    Herman   L.    Kretschmer,    in   the   chair. 

"Cloacal  Morphology  and  Its  Relation  to  Gen- 
ito-Urinary  Diseases,"  by  Dr.  B.  M.  Ricketts, 
Cincinnati,  Ohio.      (No  discussion.) 

"Phylacogens  in  Urology,"  by  Dr.  F.  W.  Rob- 
bins,  Detroit,  Mich.      (March  issue  this  journal.) 

Discussion 

Dr.  Charles  M.  Harpster,  Toledo,  Ohio: 
Mr.  President:  I  believe  Dr.  Robbins  very  nicely 
summed  up  the  situation.  I  have  found  several 
cases  at  the  very  inception  of  an  acute  arthritis, 
following  an  acute  urethritis,  in  which  the  action 
of  phylacogens  or  the  vaccines  has  been  very  re- 
markable. Just  as  an  illustration :  A  young  man 
has  a  discharge  for  forty-eight  hours,  with  swelling 
beginning  immediately  in  the  wrist,  accompanied  by 
intense,  violent  pain  and  swelling  of  hands  and  fore- 
arms. This  man  was  given  two  hundred  million 
killed  gonococci  at  once.  I  believe  in  all  these 
cases  I  have  found  this,  that  if  you  give  a  heroic 
dose  at  the  outset  you  will  oftentimes  get  results 
much  better  than  when  you  give  a  smaller  dose 
and  increase  the  dosage.  In  cases  of  acute  arthri- 
tis, with  enlargement  of  the  prostate  gland,  where 
you  can  milk  pus  out  of  the  vesicles  in  large  amount, 
the  immediate  inoculation  of  those  patients  with  the 
phylacogens  has  been  followed  in  my  hands  with 
excellent  results.  In  the  cases  of  chronic  trouble — 
that  is,  chronic  prostatitis,  seminal  vesiculitis,  no- 
dules on  the  epididymis  and  testicles,  and  so  forth 
— I  have  not  had  much  success  with  vaccine  or 
phylacogen.  I  believe  the  keynote  of  the  situation 
is  this,  that  the  acuter  the  case,  the  more  violent  the 
symptoms,  the  earlier  and  more  heroic  the  injection, 
the  better  the  results  obtained. 

Dr.  Franklin  B.  Wright,  Minneapolis: 
The  object  in  giving  vaccines  or  dead  bacteria  is 
to  stimulate  the  production  of  antibodies  in  the 
blood,  thereby  bringing  about  the  natural  end  of 
the  disease.  The  question  of  how  much  we  shall 
give  without  over-stimulating  is  the  one  which  should 
decide  the  dosage  and  frequency  with  which  we 
give  vaccines  or  phylacogens.  It  has  been  my  ex- 
perience that  small  doses  have  been  of  little  value, 
and  when  I  give  vaccines  at  all  I  usually  begin 
with  four  hundred  million,  and  after  the  first  dose 
I  do  not  hesitate  to  give  a  billion,  providing  the  pa- 
tient has  no  depression  from  the  first  injection.  I 
don't  consider  that  one  or  two  million  is  anything. 


LRepiinted    from    THE    UROLOOIC    AXD    CUTANE- 
OUS REVIEW.    March,    1916.] 

90 


I  would  not  give  it  to  one  of  my  patients.      I  give 
large  doses  or  none  at  all. 

Dr.  F.  C.  Herrick,  Cleveland,  Ohio:  I  won- 
der if  the  last  speakers  have  confused  phylac.ogens 
with  vaccines.  I  thought  they  used  the  two  terms 
almost  synonymously. 

Dr.  Wright:  I  spoke  of  vaccines. 
Dr.  Herrick :  My  experience  coincides  with 
his  as  regards  vaccines,  but  as  regards  phylacogens, 
I  have  had  practically  no  beneficial  results,  except 
in  a  very  few  acute  cases.  I  have  used  phylacogens 
also  and  more  widely  in  other  infections,  in  the 
Out-Patient  Department,  and  beyond  making  the 
patient  very  sick,  I  have  seen  no  results. 

Dr.  Franklin  B.  Wright,  Minneapolis:  I 
spoke  entirely  of  the  action  of  vaccines.  The  dif- 
ference between  the  two  is  whether  you  give  the 
exogenous  or  endogenous  toxins  which  the  bacteria 
produce  in  their  growth.  Apart  from  that,  they 
are  both  given  on  the  same  principle,  namely,  that 
of  stimulating  antibodies  in  the  blood.  The  phy- 
lacogen  gives  the  exogenous  toxin ;  the  vaccine  gives 
the  endogenous,  so  that  the  same  rule  should  apply 
to  both. 

Dr.  James  A.  Gardner,  Buffalo,  N.  Y. :  I 
would  like  to  ask  Dr.  Robbins  if,  in  these  cases 
which  he  felt  were  cured,  he  subsequently  used  any 
complement  fixation  test,  or  whether,  as  we  find  in 
many  old  vesicular  conditions,  they  quieted  down 
and  would  light  up  possibly  a  month  or  two  or  three 
later.  During  that  period  we  always  find  a  two 
or  three  plus  complement  fixation. 

Dr.  Wm.  E.  McCollom,  Brooklyn,  N.  Y.: 
Did  the  doctor  use  any  other  treatment  except  the 
phylacogens? 

Dr.  H.  L.  KrETSCHMER,  Chicago:  I  would 
like  to  ask  Dr.  Robbins,  in  closing,  to  tell  us  the 
extent  of  the  reactions  he  had  in  administering 
phylacogens  intravenously.  The  brief  report  made 
by  me,  to  which  he  referred,  was  published  several 
years  ago.  Subsequent  to  that  publication  several 
of  the  cases  treated  with  phylacogens  had  severe 
reactions.  In  one  case  particularly  the  hemoglobin 
went  down  to  fifty  per  cent.  In  several  cases  the 
patients  developed  a  marked  anemia.  I  would  like 
to  know  whether  or  not  Dr.  Robbins'  cases  had 
the  same  degree  of  anemia  and  marked  reaction 
following  the  intravenous  use  of  phylacogens. 

Just  a  few  words  in  regard  to  the  treatment  of 
these  so-called  cases  of  gonorrheal  rheumatism  with 
phylacogens  and  vaccines.  In  some  of  the  cases 
we  did  not  obtain  the  desired  results.  We  usually 
used  routine  local  treatment  plus  vaccines  and  phy- 
lacogens, and  yet  the  patients  did  not  have  the  re- 
sults from  the  treatment  that  they  should  have.  I 
was  just  wondermg  how  many  of  these  cases  had 
other  foci  of  infection.  Whether  their  joints  were 
all  due  to  the  infection  in  the  prostate  or  vesicles  or 
deep  urethra;  whether  they  did  not  have  other  foci 
of  infection,  such  as  the  tonsil.      I  think,  in  all  of 

91 


these  cases,  that  we  should  go  into  a  differential 
diagnosis  to  more  carefully  eliminate  other  foci  of 
infection. 

Dr.  a.  C.  Stokes,  Omaha,  Neb. :  I  would 
like  to  emphasize  the  point  made  by  our  chairman 
regarding  reaction.  In  Omaha  we  have  used  phy- 
lacogens  in  a  number  of  cases,  I  should  say  ten  or 
fifteen  times  in  the  hospital,  and  I  cannot  say  that 
in  any  one  particular  case  we  saw  any  good  at  all 
from  them,  and  I  think  in  most  of  the  cases  we  all 
agreed  that  there  was  more  or  less  harm  done  by 
them,  if  we  could  judge  by  those  cases.  Of  course, 
these  cases  were  almost  all  chronic  articular  cases 
of  gonorrheal  origin. 

Dr.  V.  D.  Lespinasse,  Chicago:  Lately  I 
have  not  used  phylacogens  at  all,  but  in  the  early 
days,  when  they  first  came  out,  I  used  them  on  a 
series  of  arthritic  cases,  and  I  found  that  if  we 
gave  a  large  dose  at  that  time  (from  six  to  ten  c.c.) , 
intramuscularly  or  subcutaneously,  the  beneficial  re- 
sults, if  obtained  at  all,  were  obtained  right  away. 
Tbe  patients  had  considerable  reaction,  chills,  fever 
and  so  forth.  My  experience  only  included  nine 
cases.  Half  of  them  were  cured  in  three  or  four 
days,  the  joint  pains  disappearing,  and  they  were 
able  to  get  up  and  walk  around.  Those  that  were 
not  benefited  immediately  were  given  subsequent 
doses.  So  that  I  feel  that  if  you  obtain  any  bene- 
ficial results,  you  will  perceive  them  right  away. 
Some  did  not  obtain  improvement  with  as  high  as 
twelve  injections,  given  once  or  twice  a  week.  In 
other  types  of  cases,  epididymitis,  prostatitis,  and 
so  forth,  I  have  had  no  experience. 

Dr.  Theo.  H.  Smith,  Detroit,  Mich.:  My 
experience  with  phylacogens  is  very  limited.  I,  like 
many  others,  tried  it  when  first  presented.  Several 
doses  were  given  to  me  for  experimental  use.  We 
tried  it,  of  course,  on  clinic  patients.  Our  experi- 
ence was  unsatisfactory,  with  the  exception  of  one 
patient,  and  the  interne,  in  giving  it,  gave  by  mis- 
take instead  of  one-half  c.c.  intravenously,  for  the 
first  dose,  two  c.c.  intravenously,  and  the  patient 
almost  died  that  night.  The  next  day,  however, 
his  arthritis  was  gone,  either  from  fright  or  fear  of 
getting  another  dose.  (Laughter.)  At  any  rate, 
he  was  very  nimble  and  active  after  the  reaction. 
Smce  then  we  have  not  used  it. 

Dr.  E.  G.  Mark,  Kansas  City,  Mo. :  I  would 
like  to  ask  Dr.  Robbins  if  it  is  not  so  that  we  get 
a  complement  fixation  test  after  simple  vaccines, 
whether  the  patient  ever  had  gonorrhea  or  not? 
Would  it  not  be  equally  so  in  the  use  of  phylaco- 
gens ? 

Dr.  W.  T.  Elam,  St.  Joseph,  Mo.:  Some- 
times I  thought  I  was  getting  results,  but  I  never 
could  tell  whether  they  were  due  to  phylacogens, 
or  not.  I  was  always  reminded,  when  I  used  phy- 
lacogens, of  an  old  doctor  I  used  to  know.  He 
dished  out  his  own  medicines,  and  when  he  had 
more  than  necessary  he  always  put  it  into  a  certain 

92 


bottle.  When  he  came  to  a  case  where  he  did 
not  know  what  the  trouble  was  he  used  that  medi- 
cine. (Laughter.)  As  a  matter  of  fact,  many  of 
them  got  well  in  spite  of  the  fact  that  he  did  not 
know  just  what  the  medicine  contained,  and  that 
he  gave  it  for  conditions  which  he  did  not  recognize. 

The  truth  of  the  matter  is  that  in  genito-urinary 
disease,  like  other  diseases,  many  of  our  patients 
will  get  well,  whether  we  use  phylacogens  or  not. 
Ofttimes  another  doctor  is  called  in,  and  before 
he  has  time  to  change  the  treatment  the  patient  im- 
proves and  he  gets  credit  for  the  improvement.  This 
also  occurs  where  phylacogens  has  been  used  and 
the  phylacogens  gets  the  credit. 

It  seems  to  me  that  there  is  probably  more  scien- 
tific reason  for  using  vaccines  than  using  phylaco- 
gens, providing  you  know  exactly  the  germ  you 
have,  cuid  with  cui  autogenous  vaccine  there  is  real- 
ly some  reason  for  its  use. 

As  for  phylacogens,  I  never  could  see  that  I 
got  any  results  from  them. 

Dr.  F.  W.  Robbins,  Detroit,  Mich,  (closing 
the  discussion)  :  If  anybody  knows  me  very  well 
he  knows  that  one  of  my  faults  is  conservatism.  I 
was  visited  by  the  purveyor  of  vaccines  and  phy- 
lacogens over  and  over  again,  until  so  insistent 
was  he  that  I  did  not  know  whether  he  was  a  fool  or 
I.  I  looked  over  his  great  list  of  case  reports,  one 
after  another,  but  came  across  no  name  which  was 
familiar  to  me;  these  reports  came  from  every  little 
spot  and  town  the  country  over.  I  said  that  those 
reports  meant  and  proved  nothing  to  me,  because 
anybody  can  get  reports  on  anything.  This  pur- 
veyor has  not  been  in  my  office  for  a  year  and  a 
half.  I  do  not  want  to  see  him  again.  Mean- 
while, I  had  some  little  correspondence  and  talk 
with  the  heads  of  the  Experimental  Department, 
and  I  felt  that  Parke,  Davis  and  Company  would 
injure  themselves  before  the  profession,  particularly 
by  the  way  that  phylacogens  was  put  on  the  market. 
President  Ryan  is  a  very  fine  gentleman,  but  it 
came  to  my  mind  that  Ryan  at  one  time  said  that 
he  would  trust  the  future  success  of  Parke,  Davis 
and  Company  to  the  outcome  of  the  use  of  phylaco- 
gens, and  upon  its  merits.  All  that  sort  of  thing 
got  my  goat,  as  it  were,  and  finally  I  said  to  Dr. 
Lamed  that  if  they  would  give  us  a  few  packages 
I  was  quite  sure  that  some  of  my  confreres  would 
be  glad  to  work  with  me  and  see  if  it  was  of  value 
in  urology. 

My  report  is  made  as  a  preliminary  report  on 
the  observations  of  between  fifty  and  sixty  cases.  I 
think,  rather  than  use  phylacogens  in  large  doses, 
and  getting  the  reactions  that  have  been  induced 
by  some  physicians,  I  would  rather  leave  phylaco- 
gens out  of  any  armamentarium.  I  think  the  largest 
dose  I  have  ever  given  was  six  c.c.  The  very 
fact  that  Dr.  Smith  had  a  case  in  which  he  gave 
I  0  c.c.  for  several  days,  with  marked  improvement, 
shows  me  that  either  he  had  pretty   good  control 

93 


over  the  patient  or  that  the  patient  did  get  improve- 
ment that  was  worth  the  reaction  that  he  got.  So, 
Mr.  Chairman,  in  reply  to  your  question,  I  have 
given  from  one-half  to  six  c.c,  and  have  not 
gotten  any  severe  reaction,  and  have  tried  to  limit 
the  reaction  to  a  temperature  of  101  .  In  one 
case  it  went  a  little  higher. 

In  connection  with  Dr.  Gardner's  suggestion, 
I  think  my  paper  will  practically  bear  out  this  idea 
that  phylacogens  has  no  value  in  producing  a  nega- 
tive complement  fixation  test.  If  it  did  do  that,  it 
ought  to  cure  and  help  acute  prostatitis.  I  am 
very  doubtful  whether  it  helped  cases  of  acute  pros- 
tatitis, but  I  have  seen  a  few  cases  where  the  pros- 
tate was  very  sensitive  and  large — those  cases  in 
which  you  cannot  use  any  other  treatment  and  are 
practically  put  on  the  rest  treatment.  In  those  cases 
I  have  given  phylacogens,  and  I  think  in  some  with 
beneficial  results,  although  I  am  not  at  all  sure 
about  it,  and  will  be  glad  to  carry  out  further  ob- 
servation, if  enough  interest  is  displayed  in  it  to 
make  it  worth  while. 

However,  going  into  the  thing  with  absolutely 
unbiased  mind — perhaps  more  biased  against  phy- 
lacogen  than  otherwise — I  feel  just  this  way,  that 
if  a  man  comes  to  me  with  an  acute  gonorrheal 
arthritis,  a  private  patient,  I  am  not  justified  in  let- 
ting him  go  without  the  benefit  that  I  seem  to  have 
gotten  in  other  cases  with  phylacogens. 

In  epididymitis,  I  have  been  more  and  more  im- 
pressed, since  using  the  phylacogens  to  the  exclu- 
sion of  all  other  methods  of  treatment,  that  epididy- 
mitis in  a  great  majority  of  cases  will  do  just  as 
well  under  homoeopathy  as  under  the  best  treat- 
ment we  have  ever  used.  But  I  do  think  that  in 
a  certain  number  of  cases  phylacogens  and  rest  to- 
gether— which  is  the  more  beneficial  I  do  not  know 
— will  cheat  us  out  of  a  good  many  operations. 

Dr.  Ravogli,  of  Cincinnati,  Ohio,  read  a  paper 
on  "Syphilis  of  the  Prostate."  (March  issue  this 
journal). 

Discussion. 
Dr.    Franklin    B.   Wright,    Minneapolis: 

Mr.  Chairman:  Two  years  ago  I  had  the  pleasure 
of  reporting  to  the  Chicago  Urological  Association 
a  case  of  syphilis  of  the  prostat*-,  which  corresponds 
with  the  class  of  late  syphilis  which  Dr.  Ravogli 
speaks  of.  This  patient  had  a  history  of  seven 
months'  cystitis;  had  been  watched  and  treated  for 
about  three  months  in  bed.  Suprapubic  drainage 
had  been  performed,  and  when  he  came  to  me  there 
was  a  fistula  of  five  months'  standing.  He  had  ten 
ounces  of  residual  urine  in  the  bladder  in  spite  of 
the  existence  of  the  fistula.  The  bladder  was 
washed  out  and  cystoscopic  examination  made 
through  the  urethra,  which  showed  simply  a  trabec- 
ulated  bladder.  The  posterior  urethra  was  ex- 
cessively sensitive.     Rectal  examination  at  that  time 

94 


showed  a  slightly  enlarged  prostate,  uneven  on  the 
surface,  and  nodular.  So  far  as  elesticity  was  con- 
cerned, it  was  firmer  than  normal,  but  still  did  not 
give  sensation  of  being  hard.  It  was  excessively 
tender  to  the  touch.  I  made  a  Wassermann,  which 
was  positive.  He  gave  a  history  of  having  had  an 
insignificant  sore  on  the  penis  twenty  years  before. 
After  six  weeks  the  residual  urine  was  about  three 
ounces,  and  he  went  back  home.  A  year  after- 
wards he  was  fairly  well.  His  family  physician 
laughed  at  him,  and  said  I  was  fooling  him.  It 
took  three  years  longer  to  develop  tabes,  and  last 
winter  I  saw  him,  after  the  diagnosis  had  been  con- 
firmed by  Dr.  Thomas,  at  Rochester,  and  he  now 
has  a  well-marked  tabes. 

Dr.  B.  C.  Corbus,  Chicago:  The  recognition 
of  syphilis  is  divided  into  three  given  periods,  you 
might  say.  First,  a  period  previous  to  1876;  sec- 
ond, a  period  from  1876  to  1900.  Previous  to 
1876  syphilis  was  diagnosed  by  the  pathologist 
at  the  post-mortem  table.  Prom  then  to  I  900  syph- 
ilis was  diagnosed  by  giving  specific  treatment  first. 
If  the  treatment  fitted  the  disease,  the  patient  had 
syphilis.  With  the  advent  of  the  cystoscope,  did  it 
first  become  possible  to  diagnose  syphilis  of  the 
urinary  tract,  and,  by  the  way,  our  most  estimable 
member.  Dr.  Granville  MacGowan,  was  one  of  the 
first  to  diagnose  syphilis  with  the  cystoscope. 

An  interesting  thing  concerning  secondary  syph- 
ilis is  the  secondary  syphilide,  which  is  character- 
ized by  discharge.  It  is  possible  and  probable  that 
the  way  of  infection  is  by  this  method:  The  urethra, 
teeming  with  spirochetes,  during  ejaculation  carries 
an  infection  to  the  female.  An  interesting  case  is 
cited  of  a  woman  who  had  a  husband  who  had 
syphilis,  and,  fearing  to  infect  her,  he  ejaculated  on 
the  pubes,  and  at  the  site  she  developed  a  large 
chancre.  Another  interesting  case  is  of  a  German 
soldier  who  wanted  to  escape  military  service.  He 
injected  into  his  own  bladder  some  urine  of  a  sick 
person,  and  later  on  developed  severe  cystitis  and 
secondary  syphilis. 

The  diagnosis  of  syphilis  by  the  cystoscope  is 
the  beginning  of  the  modern  diagnosis  of  syphilis. 
Syphilis  can  attack  the  bladder  and  prostate,  as  Dr. 
Ravogli  said,  during  the  period  of  secondary  locali- 
zation. The  spirochete  localizes  in  every  pore  of 
the  body.  I  have  myself  observed  in  a  Japanese 
man  the  typical  mucous  placques  on  the  bladder  mu- 
cosa, and  also  a  mild  grade  of  cystitis. 

Syphilis  in  the  tertiary  form  simulates  very  close- 
ly papilloma.  Syphilis  of  the  prostate  has  been 
reported  only  very  infrequently.  I  was  very  much 
interested  in  Dr.  Wright's  case.  I  can  find  in  the 
literature  scarcely  six  cases  of  syphilitic  prostatitis. 

Syphilis  of  the  ureter  exists,  and  it  is  in  my 
cases  of  secondary  syphilis,  and  it  would  be  a  good 
idea  in  some  of  our  cases,  where  we  can,  to  make 
the  differential  diagnosis. 

A  most  interesting  clinical   symptom   in  syphilis 

95 


is  the  acute  parenchymatous  syphiHtic  nephritis.  The 
kidney  is  involved  in  secondary  and  tertiary  syphiHs. 
Gumma  of  the  kidney  only  appears  at  autopsy.  A 
parenchymatous  syphilitic  nephritis  is  a  recognizable 
condition,  emd  calls  for  prompt  treatment. 

With  the  advent  of  our  Wassermann ;  with  the 
advent  of  the  spirochete  and  modern  cystoscope,  it  is 
not  hard  to  diagnose  these  lesions  in  the  bladder. 

In  regard  to  spinal  syphilis,  the  secondary  blad- 
der findings  in  spinal  syphilis,  we  are  all  coming 
to  know  that  a  large  percentage  of  syphilis  with 
negative  Wassermanns  on  the  blood  stream  show- 
up  sixty-five  and  seventy  per  cent,  of  tabes,  after 
negative  blood  Wassermanns.  If  we  regard  this 
test  as  final,  we  will  get  into  trouble  later  on.  Every 
case  that  comes  for  diagnosis  of  syphilis  is  not  com- 
plete until  a  spinal  fluid  examination  has  been  made. 

Dr.  G.  J.  Thomas,  Rochester,  Minn. :  In  dis- 
cussing syphilis  of  the  genito-urinary  tract,  I  might 
cite  a  case  of  intermittent  hemoglobinuria  in  a  man 
who  gave  a  history  of  lues  and  in  whom  the  Was- 
sermann test  was  positive.  The  complaint  was, 
briefly,  that  of  the  passage  of  what  the  patient 
thought  to  be  blood,  with  slight  rise  of  tempera- 
ture and  chills  after  exposure  to  cold.  The  so- 
called  blood  came  from  both  kidneys,  but  proved  to 
be  nothing  more  than  hemoglobin.  Antisyphilitic 
treatment  was  instituted  and  after  a  period  of  six 
months,  during  which  time  twelve  or  fifteen  injec- 
tions of  salvarscm  were  given,  his  symptoms,  includ- 
ing hemoglobinuria,  disappeared. 

In  the  Urological  Department  of  the  Mayo 
Clinic,  the  diagnosis  of  cord  lesion  is  frequently 
made  by  means  of  the  cystoscope  when  the  other 
manifestations  have  not  been  apparent  in  the  gen- 
eral clinical  examination.  In  some  cases  in  which 
both  the  spinal  fluid  and  blood  Wassermanns  were 
negative  we  have  been  able  to  reconstruct  a  diag- 
nosis by  referring  the  patient  back  to  the  physician 
and  urging  him  to  further  efforts  because  cysto- 
scopy revealed  a  characteristic  relaxation  of  the 
posterior  urethra  and  characteristic  trabeculation 
of  the  bladder. 

Dr.  H.  J.  ScHERCK,  St.  Louis,  Mo. :  It  has 
occurred  to  me  after  hearing  the  paper  of  Dr.  Ravo- 
gli  that  our  pathologists  have  overlooked  in  some 
cases  the  microscopic  diagnosis  of  syphilitic  disease 
of  the  prostate  gland,  or  that  this  condition  is  not 
as  frequent  as  we  are  led  to  believe  from  listening 
to  the  paper  just  read.  It  has  been  our  custom 
in  all  of  the  hospitals  with  which  I  am  connected 
to  send  the  specimen  removed  to  our  pathological  de- 
partments as  a  routine  measure,  our  object  being  to 
discover  if  possible,  any  evidence  of  malignant 
change  in  the  gland.  So  far  as  malignancy  is  con- 
cerned, our  percentage  corresponds  practically  to 
those  who  have  reported  on  this  condition  as  incident 
in  the  enlargement  of  the  prostate,  but  as  I  speak, 
I  do  not  recall  having  read  a  report  from  our  path- 
ologists in  any  one  case  in  which  a  microscopic  ex- 

96 


amination  was  made  that  any  form  of  syphilitic 
change  was  noted. 

Dr.  W.  F.  Martin,  Battle  Creek,  Mich. :  I 
observed  three  cases  this  year,  one  of  chancre  in  the 
urethra.  This  man  presented  symptoms  of  gonor- 
rhea, but  the  discharge  contained  no  gonococcus. 
Urethroscopic  examination  revealed  an  ulcer  in  the 
anterior  urethra.  I  did  not  recognize  the  active 
factor  m  this  case  until  later  secondary  symptoms 
developed,  and  this  lesion  immediately  recovered 
with  the  proper  treatment. 

Another  was  a  case  of  marked  cystitis  which  I 
suspected,  upon  examination- — both  from  the  clinical 
history  and  also  cystoscopic — to  be  tuberculosis  of 
the  bladder,  but  persistent  search  for  the  tubercle 
bacilli  did  not  reveal  them,  and  further  studies 
showed  the  patient  had  a  positive  Wassermann. 
Suitable  treatment  cleared  up  all  the  symptoms. 

I  also  had  another  patient  this  summer  with  an 
acute  nephritis  that  proved  to  be  due  to  syphilis 
— secondary  syphilis.  He  had  a  very  small 
chancre  some  three  or  four  weeks  before  I  saw  him, 
and  presented  himself  for  the  treatment  of  the  ne- 
phritis, because  of  edema  emd  rapid  pulse  and  al- 
buminuria, but  we  decided  that  this  was  due  to  the 
syphilitic  infection,  and  after  carrying  out  suitable 
treatment  he  recovered  entirely  from  the  nephritis. 

Dr.  G.  Kolischer,  Chicago:  There  are  two 
points  about  this  discussion  that  are  particularly  in- 
teresting to  me.  First,  generally  speaking,  there 
is  no  chance  of  making  a  diagnosis  of  syphilis  of  the 
bladder  by  the  mere  inspection  of  the  bladder.  There 
is  absolutely  no  characteristic  difference,  for  in- 
stance, between  a  tertiary  syphilide  of  the  bladder 
or  the  breaking-down  of  an  infiltrated  cancer.  Such 
a  diagnosis  is  impossible.  There  is  only  one  con- 
dition where  the  observer  is  bound  or  forced  to 
think  of  syphilis,  and  that  is  in  case  of  a  leu- 
koplakia of  the  bladder  which  cannot  be  distinguish- 
ed by  any  mucous  placques,  especially  if  we  use 
a  very  strong  magnifying  cystoscope,  or  bring  the 
prism  of  the  cystoscope  very  close  to  the  spot,  and 
in  this  way  enlarge  it  in  our  field.  Then  we  see 
that  this  white  speck  has  not  the  uniform  surface, 
or  that  the  surface  consists  of  a  little  white  syphilide. 
Then  we  have  to  think  of  a  syphilitic  condition.  It 
is  only  the  laboratory  tests,  in  such  bladder  condi- 
tions, that  make  the  diagnosis  definite.  The  mere 
aspect  cannot  do  it. 

Second,  as  to  the  value  of  trabeculation  of  the 
bladder  so  far  as  tabes  is  concerned :  I  have  re- 
peatedly taken  occasion  to  point  out  that  trabecula- 
tion of  the  bladder  is  pathognomonic  only  if  we 
are  in  a  position  to  exclude  all  other  causes  for 
trabeculation  of  the  bladder,  that  is,  an  obstacle 
in  the  urinary  flow,  which  leads  to  hypertrophy  of 
the  bladder,  because  it  has  to  make  increased  ef- 
forts. This  is  especially  true  if  the  man  is  of  a 
nervous  disposition.  So  that  hypertrophy  is  not  the 
product  of  extreme  effort  in  each  contraction,  but 

97 


the  product  of  such  numerous  contractions.  In 
other  words,  we  have  to  quahfy  these  statements  a 
little. 

Dr.  H.  L.  Kretschmer,  Chicago:  The  fact 
has  been  mentioned  that  syphilis  of  the  kidney 
may  cause  hematuria.  I  would  like  to  call  atten- 
tion to  Loewenhardt's  report  of  a  case  of  essential 
hematuria  in  a  woman,  in  the  days  before  the  Was- 
sermann  test  was  known.  This  patient  was  given 
K.  I.  and  mercury,  and  the  hematuria  stopped. 
Loewenhardt  assumed  that  the  woman  was  suffer- 
ing from  syphilis  of  the  kidney.  Later,  when  the 
hemorrhages  were  so  severe  that  they  would  not 
yield  to  antisyphilitic  treatment,  nephrectomy  was 
carried  out.  Examination  showed  large  amounts 
of  lymphatic  tissue  in  the  renal  pelvis.  The  condi- . 
tion  was  found  to  be  one  of  pyelitis  granulosa, 
which  was  undoubtedly  the  cause  of  the  hemor- 
rhage, and  not,  as  supposed,  a  syphilis.  So  I  think 
we  must  be  a  little  careful  in  interpreting  our  thera- 
peutic results. 

Dr.  a.  Ravogli,  Cincinnati  (closing  the  dis- 
cussion) :  I  am  glad  to  hear  that  everybody  agrees 
that  syphilis  affects  the  prostate  and  the  genito- 
urinary tract  and  bladder. 

I  agree  perfectly  with  what  Dr.  Kolischer  said, 
that  it  is  nearly  impossible  to  make  the  diagnosis 
from  the  cystoscopic  appearance  of  the  bladder, 
and  he  is  perfectly  right,  but  we  must  remember 
also  that  in  the  skin  sometimes  we  find  that  it  is  ex- 
tremely difficult  to  make  diagnoses  between  a  case 
of  variola  and  papulo-pustular  syphilide.  It  is  the 
same  thing  in  the  condition  of  the  bladder.  Of 
course,  the  Wassermann  test  and  all  the  different 
concomitant  symptoms  will  give  us  the  right  to 
make  the  diagnosis  of  syphilis  of  the  prostate. 


"Local  Anesthesia  in  Operations  of  the  External 
Genitalia  and  Prostate,"  by  Dr.  A.  C.  Stokes,  of 
Omaha,    Neb.      (February  issue  this   journal.) 

"Radiotherapy  and  Diatherm-Therapy  in  Ma- 
lignant Tumors  of  the  Bladder,"  by  Dr.  Gustav 
Kolischer,  Chicago   (February  issue  this  journal.) 

Discussion. 

Dr.  F.  C.  HeRRICK,  Cleveland,  Ohio:  Mr. 
Chairman:  I  have  been  very  much  interested  in 
Dr.  Stokes'  remarks,  particularly  because  I  have 
had  better  success.  Some  of  his  precautions  struck 
me  as  being  good  to  remember.  However,  I  can- 
not agree  with  him  as  regards  morphme.  I  think 
one-quarter  grain  of  morphine  brings  the  patients 
to  the  table  with  less  nervousness  and  more  relaxa- 
tion, in  a  numb  state,  in  itself  conducive  to  local 
anesthetic,  and  thus  they  get  along  very  much 
better. 

However,  I  am  with  him  absolutely  as  regards 
the  haste  of  the  operation.  As  he  suggests,  I  first 
take  care  of  the  skin,  waiting  perhaps  five  minutes 

98 


before  beginning  the  incision  at  all;  then  going 
through  the  skin  and  coming  down  to  the  fascia 
and  injecting  a  few  minims.  Then  inject  on  either 
side  by  stab  punctures,  first  taking  care  of  the  Une 
of  incision,  going  through  muscles  and  injecting 
again,  and  again  waiting  a  few  minutes  before 
going  into  the  peritoneum.  I  think  haste  has  given 
many  patients  more  pain  in  the  past  than  anything 
else.  I  tell  my  patients  that  if  they  have  the  least 
pain  I  will  wait.  In  that  way  I  gain  their  confi- 
dence and  have  been  able  to  do  a  number  of  ab- 
dominal operations,  and  with  quite  a  bit  of  com- 
fort to  the  patient. 

In  operations  on  the  scrotum  I  believe  there  were 
two  men  from  Boston,  Dr.  Crosby  and  another, 
who  spoke  of  performing  epididymotomy  under 
local  anesthesia.  They  injected  along  the  cord 
and  the  base  of  the  scrotum.  This  did  not  appeal 
to  me,  as  the  area  seemed  rather  hard  to  sterilize. 
I  have  performed  epididymotomy  by  grasping  the 
scrotum,  finding  the  point  I  want  to  incise  with  the 
left  hand,  and  holding  it  there.  Then,  with  the 
skin  drawn  tense  over  the  epididymis,  I  anesthetize 
the  skin  by  blebs  of  injection,  waiting  a  few  minutes, 
going  through  it,  and  then  going  deeper  with  the 
anesthetic,  and  thus  going  step  by  step,  without 
dropping  the  scrotum  until  the  epididymis  is  opened, 
drained  and  stitched.  That  can  be  done  with 
quite  a  lot  of  comfort  to  the  patient,  I  think,  and 
without  the  danger  of  wider  anesthesia,  as  men- 
tioned by  Crosby  of  Boston. 

I  have  never  performed  suprapubic  prostatectomy 
by  means  of  injection  of  novocaine.  It  is  a  good 
suggestion,  and  I  shall  use  it.  I  have  gone  into  the 
bladder  with  local  anesthesia,  and  then,  by  giving 
a  little  ether,  have  taken  out  the  prostate  very 
easily.  That  has  given  very  good  results  in  the 
cases  that  would  otherwise  lead  to  a  dangerous 
condition. 

I  think  we  can  do  very  much  more  with  local 
anesthesia,  carefully  and  slowly,  than  in  the  past. 

Dr.  R.  H.  Herbst,  Chicago:  Just  a  word 
in  favor  of  local  anesthesia  in  bladder  and  genital 
surgery. 

During  the  last  year  I  have  done  the  major 
part  of  my  work  with  local  anesthesia.  In  prosta- 
tectomy I  opened  the  bladder  with  novocaine  and 
have  gas  administered  for  the  enucleation  of  the 
gland,  as  I  have  never  succeeded  in  anesthetizing 
this  area  to  my  own  satisfaction.  I  agree  with  the 
statement  made  by  Dr.  Vevan  this  morning,  viz., 
that  much  of  the  success  of  local  anesthesia  de- 
pends upon  the  intelligence  of  the  patient.  It  is 
difficult  to  practice  this  method  upon  the  average 
clinic  patient,  who,  as  we  know,  is  not  very  intelli- 
gent. I  commonly  use  a  solution  of  calcium  and 
magnesium  chloride  with  novocaine  believing  that 
this  not  only  prolongs  but  also  intensifies  the  an- 
esthesia. 

Dr.    B.    M.    Ricketts,     Cincinnati:       About 

99 


October  6,  1  896,  I  saw  Rossa  do  the  first  opera- 
tion in  America  with  local  anesthesia,  namely,  the 
enucleation  of  an  eye.  Since  then  I  have  used  it 
with  very  great  success,  in  amputation  of  the  breast, 
gall-bladder  work,  appendectomies,  and  so  forth. 
I  used  cocaine  until  the  last  four  years.  Since  then 
I  have  been  using  novocame. 

I  am  an  advocate  of  the  extensive  use  of  local 
anesthesia.  I  saw  some  very  excellent  work  this 
morning,  and  with  one  exception  did  not  see  an 
operation  that  could  not  be  done  with  local.  I 
would  like  to  ask  Dr.  Herbst  why  he  did  not  do 
the  operation  this  morning  on  the  epididymis  under 
local. 

Dr.  Herbst  :    I  did. 

Dr.  Ricketts:  If  he  did,  the  patient  suffered. 
The  lips  were  pale.  He  gave  all  of  us  the  im- 
pression that  he  did  not  have  the  proper  local  an- 
esthesia. 

So  far  as  removing  the  prostate  is  concerned,  I 
attempted  to  remove  the  prostate  some  twenty-seven 
years  ago  under  the  influence  of  local  anesthesia, 
and  I  made  a  failure.  I  thought  I  was  ingenious 
and  got  a  piece  of  metal  into  which  I  had  teeth  cut. 
I  put  this  on  my  finger  and  endeavored  to  remove 
the  prostate  with  it,  but  failed.  I  did  not  get  suf- 
ficient local  anesthesia  to  do  it. 

I  must  congratulate  anyone  who  succeeds  in 
using  local  anesthesia.  In  Cincinnati  we  have  about 
five  hundred  thousand  people.  I  have  been  making 
observations  for  the  last  fifteen  years  on  the  use 
of  general  anesthetics,  and  have  concluded  that 
from  fifty  to  one  hundred  die  annually  from  pul- 
monary anesthesia — that  means  endocarditis,  peri- 
carditis, pulmonary  embolism,  cerebral  hemorrhage, 
pneumonia,  bronchitis  and  so  forth.  We  have  one 
hundred  million  people  in  the  United  States,  which 
means  twenty  thousand  deaths  annually  from  pul- 
monary anesthesia.  Say  it  is  ten  thousand  deaths 
from  anesthesia.  That  is  too  many.  Five  thousand 
are  too  many.  Two  thousand  are  too  many.  In 
Cincinnati  I  have  seen  two  deaths  resulting  from 
pulmonary  anesthesia  following  the  operation  of 
circumcision,  and  one  man  was  driven  out  of  the 
profession.  There  is  no  need  of  using  general  an- 
esthesia. 

I  must  compliment  the  essayist  on  his  endeavor 
in  this  line  to  bring  it  before  the  profession,  and 
make  more  general  use  of  local  anesthesia. 

Dr.  R.  H.  Herbst,  Chicago:  Replying  to 
Dr.  Rickett's  statement  that  the  patient  I  operated 
m  the  clinic  at  Rush  College  showed  evidence  of 
pain,  I  will  say  that  my  subject  was  em  unintelligent 
man  who  was  thoroughly  frightened  before  he  came 
into  the  clinic. 

If  Dr.  Ricketts  had  remained  long  enough  to  see 
the  operation  on  the  left  side  he  would  have  heard 
my  patient  admit  on  being  questioned,  that  the 
operation  on  both  sides  was  practically  painless. 

Dr.  Ricketts:      I  am  quite  sure  that  is  true. 

100 


Dr.  W.  F.  Martin,  Battle  Creek,  Michigan.: ' 
I  was  interested  in  Dr.  Stokes'  paper.  In  the  last, 
year  we  have  been  using  it  almost  entirely  in  our 
clinic.  We  have  been  doing  our  prostatectomies  by 
going  down  to  the  prostate  with  local  anesthesia, 
and  in  two  cases  we  have  done  a  complete  supra- 
pubic prostatectomy  with  the  local  anesthetic,  much 
to  my  surprise  without  pain.  I  have  always  feared 
that  in  removing  the  prostate  under  local,  there 
would  be  a  certain  amount  of  traction  pain.  In 
talking  this  over  with  Dr.  Hertzler,  he  assured  me 
that  there  is  some,  although  Allen  says  not.  I  was 
inclined  to  believe  that  Allen  was  rather  stretching 
things.  We  found  he  was  not.  However,  I  be- 
lieve that  in  prostates  it  is  best  to  anesthetize  down 
and  through  the  bladder,  and  then  use  gas-oxygen. 
I  think  gas  is  an  important  addition  to  the  equip- 
ment. Furthermore,  I  think  we  should  have  a  suf- 
ficient supply  of  syringes,  so  that  we  would  have 
no  trouble  with  one  getting  out  of  order. 

Relative  to  the  vas  work  and  the  epididymal  work, 
in  the  latter  we  have  generally  used  general  an- 
esthesia. In  the  vas  work  we  have  used  local  en- 
tirely. 

I  might  add  that  in  the  suprapubic  work,  if  one 
has  confidence  in  the  patient  (and  that  depends  a 
great  deal,  as  Dr.  Herbst  says,  on  the  intelligence 
of  the  patient),  one  need  not  have  any  trouble. 

Up  to  a  few  months  ago  we  have  been  using 
1-500  cocaine,  and  have  never  had  any  trouble. 
But  we  became  frightened  by  the  trouble  some  of 
our  confreres  experienced,  and  now  use  novocaine. 
We  use  morphine  first. 

Dr.  W.  E.  Lower,  Cleveland,  Ohio:  I  have 
been  very  much  interested  in  this  discussion.  The 
mere  fact  that  for  a  considerable  period  of  time  we 
have  been  able  to  accomplish  certain  results  by 
certain  methods,  does  not  necessarily  prove  that  those 
methods  should  be  perpetrated;  or  that  better  re- 
sults may  not  be  achieved  in  other  ways.  For  ex- 
ample, an  important  factor  in  operation  which  has 
been  practically  ignored  in  the  past  is  the  psychic 
factor.  We  know  that  at  times  just  as  great  shock 
may  result  from  psychic  as  from  physical  causes. 
For  this  reason,  it  seems  obvious  that  if  the  dan- 
gerous psychic  factor  can  safely  be  lessened  or  re- 
moved by  drugs,  then  drugs  should  be  used.  In 
our  clinic  morphia,  generally  in  combination  with 
scopolamine  is  used  for  this  purpose,  being  adminis- 
tered an  hour  or  more  before  every  operation, 
whether  it  is  to  be  performed  under  local  or  under 
general  anesthesia. 

In  prostatectomies  I  employ  the  so-called  Anocia- 
tion  method,  using  nitrous-oxid-oxygen  as  the  gen- 
eral anesthetic,  and  thoroughly  infiltrating  the  tis- 
sues around  the  prostate  with  a  local  anesthetic — 
novocaine — after  the  bladder  has  been  opened.  As 
is  well  known,  however,  it  is  quite  possible  to  re- 
move the  prostate  under  local  anesthesia  alone. 
By   the  use  of   a   special   long   curved   needle   the 

101 


tissues  around  the  prostate  can  be  so  completely 
infiltrated  with  the  local  anesthetic  that  the  gland 
can  be  enucleated  without  causing  the  patient  any 
special  discomfort. 

We  use  novocaine  for  local  anesthesia  in  cysto- 
scopic  examinations  and  intravesical  operations,  as 
we  believe  it  to  be  much  safer  than  alypin.  For- 
merely  I  advocated  the  use  of  alypin  in  these  cases, 
as  it  was  then  considered  to  be  a  harmless  drug.  I 
believe,  however,  that  a  death  which  occurred  in 
the  genito-urinary  dispensary  in  Cleveland  a  few 
years  ago,  was  probably  due  to  alypin.  The  pa- 
tient was  prepared  for  a  cystoscopy,  alypin  being 
used.  Suddenly  the  patient  became  violently  ill 
and  died.  While  we  could  not  prove  this  death 
was  due  to  alypin  we  were  strongly  suspicious  that 
such  was  the  case  and  therefore  discontinued  its 
use. 

I  was  very  much  interested  in  Dr.  Kolischer's 
paper,  and  especially  his  prospective  results.  To 
me,  operations  for  malignant  tumors  of  the  blad- 
der are  discouraging  procedures.  I  think  I  have 
tried  practically  all  methods,  none  of  which  has 
been  entirely  satisfactory.  It  is  surprising,  how- 
ever, to  see  how  comfortable  patients  can  often- 
times be  made  when  the  entire  growth  Ccmnot  be 
excised  and  the  hot  iron  is  used  to  burn  down  the 
tumor.  I  have  had  quite  a  number  of  these  cases 
in  which  after  the  operation  the  bladder  wound  has 
closed  entirely  and  the  patient  has  been  able  to 
empty  the  bladder  completely  and  has  been  free 
from  hemorrhages  which  had  occurred  before. 

If  we  can  cure  these  cases  by  the  method  de- 
scribed by  Dr.  Kolischer  it  certainly  makes  a  great 
advance  in  the  field  of  genito-urinary  surgery. 

Dr.  E.  G.  Mark,  Kansas  City,  Mo. :  I  would 
like  to  ask  Dr.  Kolischer  whether  or  not  he  used 
the  diatherm-therapy  through  the  cystoscope? 

Dr.  James  A.  Gardner,  Buffalo,  N.  Y. :  I 
was  sorry  that  Dr.  Lower  did  not  state  the  amount 
of  novocaine  he  felt  could  be  used  with  safety. 
Babcock  stated  last  year  that  you  can  use  one-half 
per  cent,  solution  as  you  would  a  salt  solution. 
Since  that  time  we  have  used  novocaine  in  prosta- 
tectomy and  various  other  operations,  doing  the 
greater  share  of  the  work  under  local,  and  have 
used  six  or  eight  ounces  of  one-half  per  cent,  solu- 
tion without  the  least  reaction.  Babcock  said  he 
felt  you  could  safely  use  a  pint  of  a  one-half  per 
cent,  solution.  I  wished  to  hear  what  Dr.  Lower, 
who  has  had  so  much  experience  with  it,  felt  could 
be  used   without   reaction. 

Dr.  French  S.  Cary,  Chicago:  I  would  like 
to  report  a  rather  unusual  case  of  pyelotomy  under 
local  anesthesia.  A  stone  was  removed  from  the 
pelvis  of  the  kidney  with  one-half  per  cent,  novocaine 
injection.  The  patient  had  a  stone  blocking  the 
pelvis  of  the  kidney.  The  other  kidney  was  the 
seat  of  a  pyelonephritis,  with  very  little  renal  func- 
tion.    We  did  not  feel  that  the  patient  should  have 

102 


an  anesthetic,  and  so  a  local  was  used  very  suc- 
cessfully. The  only  pain  experienced  was  when 
the  kidney  was  delivered,  and  this  subsided  as  soon 
as  the  pelvis  was  opened  and  the  pressure  relieved. 
The  operation  was  entirely  free  from  shock  and 
practically  no  pain  afterwards. 

Dr.  J.  S.  ElSENSTAEDT,  Chicago:  Regarding 
Dr.  Kolischer's  work  with  diatherm-therapy  and 
X-ray,  I  think  that  it  might  be  emphasized  that  the 
curative  results  are  practically  nil  as  regards  the 
X-ray's  influence  on  the  tumor  growth  itself.  The 
X-ray  unquestionably,  however,  has  three  import- 
cmt  uses  in  connection  with  malignancy  of  the  blad- 
der. First,  as  Dr.  Kolischer  said,  it  will  clear  up 
the  cystitis.  Second,  its  use  in  cross-fire  with  that 
of  mesothorium.  Third,  as  a  prophylactic  against 
secondary  involvement  following  an  operative  at- 
tack upon  the  bladder,  or  mesothorium  treatment. 
By  that  I  mean  raying  a  wide  area  particularly 
over  the  internal  lymphatics  and  given  very  deeply 
through  a  three  or  five  millimeter  filter. 

The  technic  of  the  X-ray  itself  deserves  some 
emphasis.  Short  exposures  are  stimulating  to  car- 
cinomatous growths.  That  has  been  definitely 
shown.  We  have  seen  some  cases  in  the  depart- 
ment which  undoubtedly  have  been  aggravated  by 
the  X-ray.  The  fact  to  be  emphasized  is  this,  that 
the  treatment  ought  to  be  prolonged  and  given  ex- 
tremely deep,  at  least  between  eight  and  ten  Bauer. 

In  regard  to  the  precipitms,  which  Dr.  Kolischer 
mentioned,  they  are  made  according  to  a  formula 
of  Dr.  J.  Walter  Vaughan,  of  Ann  Arbor.  We 
make  absolutely  no  claims  for  the  value  of  precipi- 
tins. Dr.  Kolischer  is  in  very  much  better  posi- 
tion than  I  to  observe  results.  He  merely  thinks 
that  he  probably  has  prevented  metastases  since  the 
precipitin  has  been  used. 

The  value  of  mesothorium  in  bladder  tumors 
cannot  be  questioned. 

Dr.  G.  J.  Thomas,  Rochester,  Minn.:  Dr. 
Judd  has  been  using  the  Percy  cautery  in  these  cases 
of  cancer  of  the  base  of  the  bladder  when  resec- 
tion is  impossible  and  the  introduction  of  meso- 
thorium during  convalescence. 

Dr.  W.  E.  Lower,  Cleveland,  Ohio:  We 
use  a  1  to  400  solution  of  novocaine  and  use  it 
ad  libitum  and  I  have  seen  no  toxic  results.  I  think 
that  weaker  solutions  might  be  effective,  but  I  have 
seen  no  poisonous  effects  from  even  a  stronger  solu- 
tion. 

Dr.  a.  C.  Stokes,  Omaha  (closing  the  dis- 
cussion on  his  part)  :  I  have  nothing  to  add.  I 
do  not  quite  agree  with  some  of  the  things  said 
here.  I  think  by  leaving  out  the  morphine  a  whole 
lot  of  the  psychical  shock  is  done  away  with.  That 
may  seem  a  very  strange  expression,  opposite  to 
what  most  men  have  said  and  felt,  but  my  patients 
have  not  experienced  so  much  shock.  They  used 
to  get  pale  about  the  middle  of  the  operation,  but 
since  quitting  the  use  of  the  morphine  they  do  not 

103 


get  pale  so  often.     And  so  I  still  think  we  should 
do  without  the  morphine  as  much  as  possible. 

I  have  never  seen  any  bad  results  from  alypin. 
I  still  believe  that  if  we  use  it  in  dilutions  of  I  -400, 
that  is  pretty  nearly  plain  water.  Of  course,  we 
know  that  Halsted  showed  us  years  ago  that  even 
sterile  water  has  a  certain  local  anesthetic  effect. 

Novocaine  in  one-half  per  cent,  solutions  has 
some  toxic  effects.  I  think  it  should  be  used  with 
some  care. 

One  thing  I  wanted  to  emphasize,  namely,  that 
pulling  and  dragging  must  not  be  exercised  under 
local  anesthesia.  All  the  dissections  must  be  made 
by  sharp  instruments.  It  is  wonderful  how  very 
few  instrument  makers  there  are  selling  good  in- 
struments around  the  country. 

Dr.  G.  Kolischer,  Chicago  (closing  the  dis- 
cussion) :  I  did  not  enter  into  the  technic  of  dia- 
therm-therapy  and  mesothorium,  because  they  have 
already  been  published. 

In  answer  to  Dr.  Mark's  question,  we  must  dif- 
ferentiate between  fulguration  and  diathermism. 
Fulguration  is  the  use  of  a  spark  produced  by  a 
high  frequency  current.  Diathermism  is  the  coagu- 
lation of  tissue  without  producing  a  spark.  We 
don't  want  to  produce  a  spark.  It  is  impossible  to 
introduce  the  electrodes  that  are  necessary  in  such 
a  procedure,  in  using  this  immense  amperage, 
through  a  cystoscope.  We  prefer  to  introduce  both 
electrodes  into  the  bladder  for  two  reasons:  In 
using  such  a  powerful  current  there  is  always  a 
danger  in  placing  an  electrode,  if  very  large,  on  the 
body,  because  it  may  become  detached,  and  if  de- 
tached to  a  great  extent  we  are  sure  to  produce  a 
burn  on  the  skin.  Second,  it  is  much  easier  to  get 
between  the  two  electrodes  in  high  position.  You 
can  change  your  electrodes  in  order  to  get  the 
shortest  route  from  one  pole  to  the  other,  and  that 
is  the  reason  we  use  diathermism.  Mere  fulgura- 
tion would  not  enter  at  such  a  depth.  It  does  not 
destroy  tissue  to  such  an  extent  as  the  cooking  of 
the  tissue.  With  this  diathermism  we  can  boil 
down  a  pound  of  steak  inside  of  fifteen  minutes  to 
a  leathery  flap. 

All    the   other    technical    details   will    be   dwelt 
upon  in  a  publication  by  Dr.  Schmidt  and  myself. 


"Chronic  Edema  at  the  Vesical  Neck  Causing 
Symptoms  Resembling  Hypertrophy  of  the  Pros- 
tate," by  Dr.  H.  J.  Scherck,  St.  Louis,  Mo.  (Feb- 
ruary issue  this  journal.) 

"Non-Calculous  Obstruction  of  the  Upper  Ure- 
ter," by  Dr.  G.  J.  Thomas,  Rochester,  Minn. 
(See  March  issue  this  journal.) 

"Free  Oxygen-Gas  Treatment  of  Urinary  Tu- 
berculosis," by  Dr.  W.  F.  Martin,  Battle  Creek, 
Mich. 


104 


Discussion. 

Dr.  H.  W.  Plaggemeyer,  Detroit,  Mich.: 
Mr.  Chairman:  In  regard  to  the  point  brought  out 
by  Dr.  Thomas,  namely,  that  in  a  number  of  cases 
of  hypertrophy  they  have  noticed  a  parenchymatous 
involvement  as  well,  verified  by  the  fact  that  the 
color  test  was  appreciably  higher  than  one  would 
expect  from  the  radiographic  picture,  I  quite  agree 
with  him.  I  have  seen  a  number  of  cases  that  were 
surprisingly  high,  but  I  do  not  think  that  this  is  in 
any  way  derogatory  to  the  colorimetric  functional 
test.  I  think  the  chief  value  to  be  obtained  from 
such  a  case  is  to  give  us  an  idea  as  to  the  reserve 
force  of  the  kidney.  We  are  prone  not  to  differen- 
tiate between  the  anatomic  and  pathologic  lack 
of  integrity  on  the  one  hand  and  the  functional 
integrity,  on  the  other  hand.  And  this  test,  of 
course,  gives  us  a  very  good  index  of  the  functional 
reserve  force  of  the  kidney,  especially  if  the  curve 
is  a  sharp,  quick  curve  in  the  catheterized  speci- 
men the  first  fifteen  minutes. 

If  the  curve  is  an  even  curve  in  both  fifteen 
minutes,  or  lower  in  the  first  than  second,  it  shows 
that  the  kidney  is  working  to  its  maximum  capacity 
at  that  time  at  least.  It  is  essential  to  know  that 
functional  capacity  in  addition  to  knowing  the 
usual  findings. 

Dr.  Wm.  E.  McCollom,  Brooklyn:  I  just 
wish  to  call  attention  to  a  few  points.  Dr.  Thomas 
mentioned  the  fact  that  the  colon  bacilli  were  pres- 
ent. I  wish  to  ask  if  they  are  doing  blood  cultures 
in  those  cases.  I  have  in  mind  a  case  or  two  in 
which  vaccines  from  the  kidney  pelvis  seemed  to  be 
not  sufficient  to  relieve  the  kidney  condition,  and 
blood  cultures  of  both  kidneys  proved  to  be  strep- 
tococcus. The  condition  was  cleared  up.  I  have 
under  treatment  at  the  present  time  three  cases  in 
which  I  have  been  able  to  clear  infection  of  the 
kidney  pelvis  with  injection  of  living  Bulgarian  ba- 
cilli. Koch  made  the  preliminary  report  on  this 
work.  My  bacteriologist  suggested  the  trial.  It 
was  first  tried  on  a  case  of  pyelitis,  in  which  every 
possible  means,  such  as  vaccines  and  kidney  lavage, 
was  used,  and  the  last  five  attempts  to  secure  cul- 
tures of  the  kidney  have  failed.  Of  course,  we  do 
not  use  any  urinary  antiseptic  when  instilling  the 
Bulgarian  bacilli  into  the  pelvis,  and  the  Bulgarian 
bacilli  alone,  so  far  as  I  can  tell,  have  cleared  up 
the  infection  in  this  case,  as  well  as  two  others, 
which  I  have  had. 

Dr.  Meyers,  of  Brooklyn,  mentioned  some  years 
ago  that  simple  dilation  of  the  ureters  and  better 
drainage  would  be  of  some  effect,  and  I  think  that 
is  probably  the  case.  In  these  three  cases,  how- 
ever, I  have  seen  some  good  from  the  Bulgarian 
bacilli.  I  have  wondered  whether  it  was  the  Bul- 
garian bacilli  or  the  lactic  acid  that  has  brought 
about  the  result.  These  cases  have  not  been  dis- 
charged, and  I  am  watching  them  with  considerable 
interest.      I    feel    that   the   results   have   been    such 

105 


that  I  shall  continue  the  work.  I  have  failed  in 
many  cases  of  lavage  of  the  kidney,  with  silver 
nitrate,  and  other  remedies.  I  think  that  has  been 
generally  so,  and  any  new  method  of  this  kind, 
which  would  seem  to  bring  results,  I  think  would 
be  worth  an  attempt. 

Dr.  G.  Kolischer,  Chicago:  I  would  like 
to  call  attention  to  the  so-called  functional  tests, 
whether  done  in  the  old-fashioned  way,  to  get 
green,  blue  or  red  urine,  or  in  other  ways.  All 
these  classifications  of  the  test  are  nothing  but  ex- 
cuses. In  my  experience,  and  the  experience  of 
others,  for  instance,  Rovsing,  it  has  been  proven 
repeatedly  that  after  removal  of  the  kidney  when 
all  so-called  functional  tests  were  prohibitive  of 
such  removal,  the  patient  was  impudent  enough  to 
stay  alive.  On  the  other  hand,  during  the  last 
two  years  extensive  experiments  have  been  made  at 
Cook  County  Hospital.  There  were  a  number  of 
patients  under  observation,  and  Dr.  Walter  Ham- 
burger, with  modern  tests,  proved  that  the  kid- 
neys were  up  to  the  top-notch— could  not  be  bet- 
ter. One  of  these  patients  had  so  little  scientific 
conscience  that  he  died  from  uremia  shortly  after- 
ward. 

As  to  edema  of  the  prostate,  I  understood  that 
Dr.  Scherck  was  attacked  lately  at  the  meeting  of 
the  American  Urological  Association  for  making 
the  statement  that  edema  of  the  prostate  would  oc- 
cur to  such  an  extent  that  it  might  simulate  hyper- 
trophy. I  am  quite  sure  that  there  is  such  a  con- 
dition. The  first  two  cases  I  observed  some  years 
ago,  when  Dr.  McKenna  was  associated  with  me. 
The  first  case  was  rather  embarrassing  because  I 
tried  to  demonstrate  my  technic  of  suprapubic  pros- 
tatectomy. After  opening  the  bladder  the  tumor 
disappeared.  Since  then  I  have  seen  several  such 
cases. 

I  would  like  to  call  attention  to  one  diagnostic 
point  during  operation.  Any  time  you  expose  the 
bladder  and  find  a  very  thin  wall,  you  have  to  think 
of  this  edema;  that  there  is  an  hypertrophy  of  the 
prostate  and  constant  obstruction  to  the  flow  of 
urine,  which  would  lead  to  concentric  hypertrophy 
of  the  bladder  wall.  How  it  could  be  diagnosed 
before  the  bladder  is  opened,  I  do  not  know.  It 
can  be  seen  afterwards.  The  tumor  appears  under 
your  eyes.     It  is  a  fact. 

Dr.  James  A.  Gardner,  Buffalo:  I  cannot 
allow  the  occasion  to  pass  without  speaking  of  Dr. 
Thomas'  paper.  I  think  he  has  been  very  conser- 
vative in  his  report  of  the  good  resulting  from  lav- 
age of  the  pelvis.  I  feel  that  lavage  of  the  pelvis 
does  more  to  cure  up  these  cases  of  pyelitis  than 
any  other  thing.  Possibly  the  doctor  has  been  so 
conservative  in  reporting  the  so-called  cures  be- 
cause he  wished  to  be  very  sure,  and  in  the  use  of 
silver  nitrate,  as  he  states,  pus  will  be  found  pos- 
sibly for  weeks  after  its  use.  If  these  patients  could 
be  observed  for  a  greater  length  of  time  possibly  the 

106 


pus  would  disappear.  That  is  a  difficulty  at  Roch- 
ester. They  do  not  have  the  opportunity  to  prove 
up  the  number  of  cases  that  are  really  helped  by 
the  lavage.  Therefore,  the  feeling  that  this  lavage 
is  not  of  importance  should  not  prevail  because  it 
has  been  such  a  distinct  advance  that  its  importance 
should  be  emphasized. 

Dr.  Frederick  Charlton,  Indianapolis, 
Ind. :  One  of  the  San  Francisco  men  this  sum- 
mer, at  the  Section  meeting  of  the  American  Medi- 
cal Association,  read  a  paper  on  cryoscopy,  going 
into  the  subject  at  considerable  length.  It  was  dis- 
cussed in  various  ways  and  with  that  discussion  in 
mind  I  rise  to  ask  Dr.  Kolischer  a  question.  Years 
ago  I  heard  him  read  a  paper  on  this  subject  and 
now  wonder  if  his  views  remain  the  same.  I  find 
myself  vacillating  between  two  opinions.  One  time 
I  believe  the  thalein  test  to  be  of  service,  and  the 
next  time  I  am  very  doubtful  of  its  value.  I  have 
never  done  cryoscopy,  feeling  that  while  it  may  be 
remotely  helpful  yet  it  cannot  have  much  place  in 
the  field  of  ordinary  everyday  work.  I  would  like 
to  know  whether  Dr.  Kolischer  has  lost  his  enthu- 
siasm for  cryoscopy,  as  he  seems  to  have  lost  it  for 
the  color  tests. 

Dr.  G.  Kolischer,  Chicago:  In  answer  to 
Dr.  Charlton,  I  will  say  that  he  misunderstood  me 
in  the  paper  referred  to.  The  paper  was  a  criticism 
of  cryoscopy,  as  of  other  functional  tests.  That  is, 
we  test  first  the  urine ;  then  pass  a  stain  through  the 
kidney,  and  then  test  it  again.  By  the  opposition 
of  any  particles  through  the  secreting  cells  a  patho- 
logical kidney  function  will  be  interfered  with,  so 
as  to  create  a  stcmdard  for  each  kidney.  We 
thought  we  did  that,  to  a  certain  extent,  at  that  time. 
I  mention  this  fact,  that  it  is  impossible  to  create 
an  arbitrary  standard  for  a  kidney.  If  it  does  not 
come  up  to  our  presumptive  standard,  we  say  it  is 
no  good.  So  I  criticized  cryoscopy,  the  same  as  all 
the  other  so-called  functional  tests,  because  I  think 
they  are  no  good.  I  am  so  convinced.  The  results 
prove  it,  although  theory  may  be  in  favor  of  it. 
Remove  one  kidney,  and  all  the  so-called  functional 
tests  say  you  would  not  dare  to  remove  it,  because 
its  mate  does  not  come  up  to  the  standard,  and  the 
patient  is  still  alive.  After  these  tests  I  have  found 
that  the  patient  has  two  absolutely  perfect  kidneys, 
and  yet  died  afterwards  from  uremia.  Either  the 
test  or  the  patient  is  no  good — I  don't  know  which. 
Dr.  R.  H.  HerbsT,  Chicago:  A  question 
relative  to  the  subject  of  edema  of  the  prostate, 
viz. :  Whether  some  of  these  cases  thought  to  be 
edema  of  the  prostate  might  possibly  be  cysts  of 
the  utricle. 

Dr.  E.  G.  Mark,  Kansas  City,  Mo.:  In  the 
discussion  of  kidney  functions  this  afternoon,  I 
rather  think  there  has  been  one  good  point  over- 
looked, namely,  the  relative  blood  urea  retention 
as  regards  the  urine.  That  patient,  of  course,  must 
be  put  upon  a  certain  diet,  knowing  the  amount  of 

107 


ingestion  of  urea  or  proteids,  and  so  forth.  I  think 
we  are  then  in  a  better  position  to  judge  more  about 
the  condition  of  that  kidney  by  means  of  relative 
blood,  urine  and  urea  retention,  than  by  any  other 
means. 

I  must  say  that  so  far  the  thalein  test  has  proved 
fairly  satisfactory  in  my  hands. 

Dr.  W.  E.  Lower,  Cleveland,  Ohio:  I  want 
to  ask  Dr.  Thomas  whether  he  has  ever  had  a  case 
in  which  these  tumors  have  suddenly  disappeared. 
I  have  had  one  case  in  which  a  cyst  of  the  pros- 
tate obstructed  the  urinary  outlet,  causing  residual 
urine.  A  cystoscopic  examination  revealed  a  smooth, 
round  tumor,  having  the  appearance  of  being  a 
part  of  the  prostate.  I  started  to  do  a  suprapubic 
prostatectomy  and  while  shelling  out  this  tumor  it 
suddenly  collapsed  and  I  felt  the  contents  escaping. 
Upon  examination  I  found  the  cyst  had  been  filled 
with  a  whitish  fluid.  The  sac  was  dissected  out. 
This  was  apparently  a  so-called  cyst  of  the  pros- 
tate. I  do  not  know  how  frequently  these  cystic 
tumors  occur  as  this  is  the  first  case  I  have  seen  and 
I  am  sure  they  are  not  very  frequently  reported. 

Just  a  word  m  regard  to  the  functional  tests; 
we  have  always  felt  that  the  phenolsulphonephtha- 
lein  test  is  a  very  good  mdication  of  what  the  kid- 
ney was  doing  at  the  particular  time  the  test  is 
used,  but  that  it  does  not  give  us  definite  mforma- 
tion  as  to  what  the  kidney  may  do  under  different 
conditions.  However,  I  am  not  quite  so  pessimistic 
as  Dr.  Kolischer. 

Dr.  H.  L.  Kretschmer,  Chicago:  In  re- 
gard to  Dr.  Scherck's  paper,  I  believe  his  case  was 
one  of  edema  of  the  vesical  neck.  I  believe  that 
when  he  opened  the  bladder  the  edema  disappeared. 
Why  did  that  patient  have  edema  of  the  vesical 
neck?  That  is  the  point  that  interests  me.  If  we 
will  stop  and  go  over  the  history.  Dr.  Scherck  said 
that  that  patient  had  edema  of  the  feet,  hemorrhoids 
and  organic  disease  of  the  heart.  Certainly,  the 
hemorrhoids  and  the  edema  of  the  feet  are  evi- 
dences of  broken  compensation,  and  I  see  no  reason 
why  he  should  not  have  edema  of  the  vesical  neck 
as  well  as  of  the  feet.  I  think,  therefore,  that  the 
edema,  in  this  particular  instance,  was  one  of  the 
evidences  of  broken  compensation.  I  do  not  be- 
lieve the  condition  was  due  to  a  cyst  of  the  pros- 
tate. 

I  have  had  the  good  fortune  to  see  two  cases  of 
cyst  of  the  prostate.  One  case  I  saw  early  in  my 
career,  when  associated  with  Dr.  Schmidt.  A  few 
years  ago  I  saw  a  similar  case.  From  my  cysto- 
scopic findings  I  made  a  diagnosis  of  cyst  of  the 
prostate.  I  decided  to  puncture  this  cyst  with 
Young's  cystoscopic  rongeur.  Before  I  could  open 
the  rougeur,  however,  I  had  poked  a  hole  into  it, 
and  it  immediately  disappeared. 

I  think  that  the  most  important  point  to  be 
brought  out  in  this  discussion  is  one  of  diagnosis. 
Often  one  sees  patients  who  have  had  pelvic  lavage 

108 


carried  out  for  a  year  or  two.  The  thought  upper- 
most in  our  mind  should  be.  Why  has  the  treatment 
failed?  The  answer  to  this  should  be  a  complete 
examination  to  determine  the  cause  of  the  failure. 

I  recall  one  instance  in  which  a  woman  was  treat- 
ed for  a  long  time  with  pelvic  lavage,  vaccines  and 
other  accessory  treatments,  without  result.  The 
first  thmg  I  did  was  to  have  an  X-ray  made,  and 
it  showed  that  she  had  a  recurrence  of  a  pelvic 
stone. 

I  think  lavage  has  a  permanent  place  in  the  treat- 
ment of  these  pyelitis  cases. 

Dr.  C.  M.  McKenna,  Chicago:  With  re- 
gard to  the  case  of  Dr.  Scherck,  namely,  edema  of 
the  bladder,  I  think  a  great  many  of  those  cases 
are  due  to  pressure.  I  have  seen  three  cases,  one 
of  which,  a  tumor,  presented  itself  above  the  pubis, 
but  went  down  immediately.  In  the  next  case  a 
large  tumor  mass  showed  after  the  bladder  was 
opened.  It  also  went  down  and  showed  quite  a 
large  prostate  gland  afterwards.  I  think  that  the 
tumor  itself  was  due  more  to  pressure  of  the  urine 
on  the  covering  of  the  prostate  gland.  Both  of  the 
cases  reported  recovered  and  have  had  no  recur- 
rences. 

Dr.  James  A.  Gardner,  Buffalo,  N.  Y. : 
Just  a  word  in  defence  of  the  thalein  test,  if  neces- 
sary, because  what  Dr.  Kolischer  has  said  rather 
damns  the  whole  thing  without  giving  it  a  chance. 
I  feel  that  the  Wassermann  test  and  the  microscope 
are  not  perfect  but  we  use  them  as  an  aid  in  the  ma- 
jority of  cases.  I  do  not  think  any  functional  test 
cem  be  said  to  be  absolute  but  even  if  there  is  a 
failure  or  small  percentage  of  failures,  it  should  not 
be  brushed  aside.  In  certain  cases  the  functional 
test  gives  us  the  cue  as  to  the  poor  operative  risk, 
which  we  otherwise  might  not  have  recognized,  so 
that  we  build  up  the  patient  before  operation  and 
shorten  the  convalescence. 

I  agree  with  Dr.  Kolischer  that  some  of  these 
men  are  so  unscientific  and  that  they  have  not  done 
as  well  as  we  had  expected,  but  you  can  quote  from 
blood  tests  where  the  Wassermanns  were  negative 
and  demonstrate  syphilis  afterwards.  This  may  be 
due  to  faulty  technic.  That  is  so  even  with  the 
stethoscope.  Many  times  we  do  not  find  things 
but  that  is  the  fault  of  the  man  using  the  stethoscope. 

Many  of  the  functional  tests  have  been  of  great 
aid  since  we  have  specific  results  to  stand  up  by. 

Dr.  H.  J.  Scherck,  St.  Louis,  Mo.  (closing 
the  discussion)  :  In  closing  I  desire  to  emphasize 
again  the  firm  opinion  that  I  hold  that  a  superim- 
posed edema  on  a  slightly  enlarged  prostate,  as 
well  as  on  a  very  decided  enlargement  is  a  common 
occurrence.  The  practical  deduction  from  this  con- 
clusion seems  to  be  that  as  a  temporizing  surgical 
procedure  certain  procedures  may  be  undertaken 
that  may  reduce  the  edema  and  give  the  patient  re- 
lief for  a  certain  length  of  time.  These  procedures 
may  not  be  of  a  nature  to  afford  any  permanent  re- 

109 


lief,  but  may  serve  as  a  useful  purpose  in  delaying 
the  operation  until  a  future  time  when  the  patient  be- 
comes in  a  better  condition  to  stand  the  major  sur- 
gical procedure.  I  am  quite  certain  the  case  that  I 
reported  was  not  one  of  cyst  of  the  prostate  as  sug- 
gested by  one  of  the  gentlemen  present,  for  the 
reason  that  the  edema  disappeared  without  a  direct 
incision  into  the  gland  but  the  mass  became  reduced 
by  a  depletion  incident  to  the  division  of  the  bladder 
wall. 

Dr.  Kretschmer's  explanation  appeals  to  me  as 
being  more  in  line  with  the  case  reported  and  m 
my  paper  I  suggested  the  possibility  of  a  condition 
described  by  Dr.  Kretschmer  as  being  the  cause. 
The  compression  of  the  gland  and  lower  vesical 
outlet  by  the  fibrous  sheath  may  have  a  bearing  on 
this  production.  I  have  been  so  much  impressed 
with  the  fact  that  the  condition  of  edema  of  the 
lower  vesical  orifice  involving  the  prostate  is  of  such 
a  common  occurrence  and  with  this  case  in  mind 
in  which  this  demonstration  was  absolute,  the  recital 
of  this  case  has  seemed  to  me  to  be  of  sufficient  in- 
terest to  have  made  a  report  of  same  before  the 
meeting.  The  discussion  which  it  has  brought  out 
confirms  me  further  in  my  belief. 

Just  a  word  as  to  the  value  of  the  phenol- 
phthalein  test.  The  longer  I  make  use  of  this  test 
as  an  indication  for  kidney  sufficiency,  the  more  I 
lean  to  the  belief  as  expressed  by  my  friend.  Dr. 
Kolischer.  In  certain  types  of  kidney  condition 
and  in  certain  times  of  the  individual's  life  it  may 
have  some  bearing  in  estimating  the  potency  of  the 
kidney  function,  but  I  am  yet  to  be  convinced  that 
because  a  kidney  will  excrete  a  dye  stuff  in  a  cer- 
tain length  of  time,  that  the  bi-products  of  meta- 
bolism will  be  handled  by  the  kidneys  in  the  same 
manner.  This  conclusion  has  been  forced  on 
me,  not  only  from  a  theoretical  standpoint,  but  on 
account  of  certain  results  that  have  been  obtained 
experimentally  in  the  wards  of  our  hospitals. 

Dr.  G.  J.  Thomas,  Rochester,  Minn,  (clos- 
ing the  discussion)  :  Regarding  functional  tests, 
a  case  should  not  be  operated  on  the  findings  of  the 
functional  tests  alone.  It  must  be  remembered  that 
the  functional  test  is  a  corroborative  laboratory 
method  and  not  the  decisive  factor  in  the  diagnosis 
of  surgical  lesions.  Used  in  this  manner,  it  has  in 
a  few  cases  helped  us  to  get  on  the  right  path :  For 
instance,  a  man  with  hematuria  came  to  the  clinic 
during  the  interval  for  examination.  A  differential 
functional  test  immediately  indicated  the  kidney 
which  contained  the  tumor,  the  existence  of  which 
was  later  proved  by  the  pyelogram.  Unless  this 
patient  could  have  been  cystoscoped  when  bleeding, 
the  diagnosis  could  not  have  been  made  without  the 
aid  of  the  functional  test. 

With  regard  to  blood  cultures,  they  were  not 
made  in  these  cases.  We  now  make  blood  cultures 
as  a  routine  procedure  in  all  cases  of  residual  urine 

110 


with  prostatic  involvement  and,  also,  in  all  infec- 
tions of  the  upper  urinary  tract. 

As  to  the  Bulgarian  bacilli,  we  have  used  them 
in  the  bladder,  but  not  in  the  kidney.  We  have 
had  good  results  in  some  of  the  bladder  cases  but 
have  employed  the  method  in  so  few  cases  that  I 
do  not  like  to  report  the  ultimate  results  from  this 
small  experience. 

As  Dr.  Gardner  mentioned,  I  did  not  emphasize 
lavage  of  the  pelvis  for  the  reason  that  many  of 
these  cases  live  a  great  distance  away.  My  state- 
ments were  based  on  the  results  of  examination  and 
not  on  what  the  patients  wrote  regarding  their  con- 
dition. It  was  not  possible  to  cystoscope  them  after 
prolonged  treatment,  but  as  long  as  they  were  at 
the  clinic  I  insisted  on  the  urine  being  free  from 
pus  before  pronouncing  a  cure.  When  silver  ni- 
trate is  employed,  this  is  not  always  possible,  but 
many  of  these  patients  were  culturally  free  from 
organisms.  From  the  number  of  cases  in  which 
the  urine  did  clear  up,  it  is  apparent  that  pelvic 
lavage  is  the  best  procedure  in  the  treatment  of 
pyelitis  and  pyelonephritis. 

At  the  Saturday  afternoon,  November  1 3th, 
1915,  session,  the  following  papers,  passed  over 
from  the  Friday  session,  were  read : 

Dr.  F.  R.  Charlton,  Indianapolis:  "A  Very 
Unusual  Case  History  Presenting  Among  Other 
Features  a  Cystoscopic  Burn."  (See  February 
issue  this  journal.) 

Dr.  W.  S.  Ehrich,  Evansville:  "The  Bladder 
in  Early  Tabes."  (See  February  issue  this  journal.) 

Dr.  E.  G.  Mark,  Kansas  City:  "A  New  Type 
of  Operating  Urethroscope."  (See  February  issue 
this  journal.) 

Discussion. 

Dr.  Robert  H.  HerbsT,  Chicago:  In  con- 
nection with  Dr.  Ehrich's  paper  I  wish  to  briefly 
give  the  history  of  a  case  which  I  reported  at  the 
last  meeting  of  the  Urological  Society. 

Patient  T.  K.  Age  50.  Denies  gonorrhea. 
Fourteen  years  ago,  age  36,  developed  a  lesion 
on  the  penis  which  he  states  was  burned  off.  Denies 
ever  having  had  eruptions  on  the  skin  or  lesions  in 
the  mouth.  About  7  years  ago  developed  loss  of 
sexual  power  at  about  the  same  time  he  noticed 
some  difficulty  in  starting  the  urinary  stream.  With- 
in six  months  after  this  he  began  to  have  frequent 
and  imperative  urination,  being  compelled  to  urinate 
about  every  two  hours  diurnally  and  from  five  to 
seven  times  at  night.  He  also  complained  of  supra- 
pubic pain,  for  all  of  which  he  was  given  bladder 
treatments. 

For  the  last  three  years  has  had  a  dull  pain  above 
the  eyes  and  severe  headaches.  Examination  of 
eyes  made  just  previous  to  time  at  which  he  came 
into  our  hands  disclosed  the  following:  Arterio- 
sclerosis of  retinal  vessels  and  very  red  disc,  with 

111 


blurring,  suggesting  an  optic  neuritis.  No  error  of 
refraction  worth  considering. 

Neurological  findings  at  about  the  same  time 
showed  reflexes  slightly  inhibited. 

Four  years  ago  developed  severe  gastric  crises 
for  which  a  gastrotomy  was  performed.  Pains  in 
stomach  have  continued  since. 

Upon  examination  we  found  urine  containing  pus. 
Examination  of  urethra  and  bladder  neck  gave  no 
evidence  of  any  obstruction.  However,  cysto- 
scopic  examination  revealed  a  marked  trabeculation 
of  the  bladder.  A  Wassermann  test  made  at  this 
time  was  strongly  positive. 

If  you  will  look  over  this  history  you  will  note 
that  this  patient  evidently  contracted  syphilis  four- 
teen years  ago  and  that  seven  years  later  he  noted 
two  symptoms  which  we  so  commonly  see  early  in 
the  development  of  spinal  cord  syphilis,  viz.,  loss 
of  sexual  power  and  difficulty  in  starting  the  urin- 
ary stream. 

Being  a  non-believer  in  the  condition  known  as 
atony  of  the  bladder  as  a  cause  of  urinary  stasis, 
there  are  left  just  two  possibilities  as  to  the  cause 
of  retention  in  this  case.  1  st.  Obstruction.  2nd. 
Interference  with  the  innervation  to  the  bladder. 
As  stated  before  at  the  time  of  our  examination 
there  was  no  evidence  of  any  obstruction. 

You  will  also  note  that  his  eye  symptoms  did  not 
appear  until  years  after»the  urinary  and  sexual  dis- 
turbances. 

Had  this  patient's  urinary  symptoms  been  inves- 
tigated seven  years  ago  and  a  trabeculated  bladder 
found  without  obstruction  as  the  cause  there  could 
have  been  but  one  interpretation  possible,  viz.,  a 
beginning  chcuige  in  the  spinal  cord.  Had  he  been 
given  appropriate  treatment  at  this  time  I  feel  cer- 
tain that  his  optic  nerves  might  have  been  saved 
and  the  gastrotomy  which  was  evidently  performed 
for  gastric  crises  could  surely  have  been  avoided. 

Dr.  B.  C.  CorbUS,  Chicago:  Syphilis  of  the 
bladder  is  only  part  of  the  passing  show  in  general 
syphilis.  The  cord  can  be  attacked  in  any  of  its 
segments.  The  blood  Wassermann  does  not  amount 
to  anything  in  tabes  in  60  per  cent.  At  the  time 
we  get  bladder  symptoms  it  is  too  late  to  do  any 
good.  During  the  last  two  years  I  have  made  1  50 
punctures.  Syphilis  localizes  in  some  individuals 
in  the  muscles,  skin,  etc.,  and  in  others  early  in  the 
spinal  canal.  It  is  our  duty  in  every  case  that 
comes  to  us,  if  there  is  a  previous  history  of  syph- 
ilis, to  take  the  Wassermann.  The  time  to  do  any 
good  is  early  and  you  must  make  a  spinal  fluid 
investigation  of  every  case  with  syphilis.  I  cannot 
agree  that  trabeculation  of  the  bladder  is  an  early 
sign  of  tabes. 

Dr.  E.  G,  Mark,  Kansas  City,  Mo.:  I  be- 
lieve that  the  general  practitioner  or  even  the  neu- 
rologist if  approached  with  the  same  symptoms  as 
have  been  presented  in  a  number  of  cases  we  have 
seen,  would  not  have  made  the  diagnosis.     Take 

112 


these  same  cases  and  spot  them  out  and  tell  them, 
"Here  is  a  case  of  tabes,"  and  the  neurologist  will 
find  eye  reflexes,  the  achilles  reflex  gone,  etc. 

An  interesting  early  case  came  to  us  a  short  time 
ago  in  which  the  patient  had  a  chronic  urethritis. 
At  the  time  we  questioned  him  as  to  his  general 
history.  He  gave  no  history  and  denied  any  history 
of  a  sore.  In  treating  the  case  in  using  a  posterior 
instillator  it  was  found  there  was  some  residual. 
This  was  finally  called  to  my  attention  by  my  as- 
sistant, and  we  cystoscoped  him.  The  findings, 
to  my  mind,  in  spite  of  what  Dr.  Corbus  has  said, 
were  typical  of  tabes.  There  is  no  doubt,  as  Dr. 
Corbus  says,  the  vesicular  crises  in  the  bladder  may 
be  something  else.  We  may  have  gastric  crises 
and  other  vesicular  crises  in  which  there  is  no  sign 
in  the  bladder;  but  in  this  case  there  was  a  very 
prominent  intraureteral  ridge,  and  post-trigonal  to 
the  side  and  back  of  the  ureters,  fine  trabeculation. 
We  do  not  expect  to  find  a  Rhomberg  except  in 
late  cases,  nor  do  we  expect  to  find  much  loss  of 
patellar  reflexes.  This  man's  achilles  reflex  was 
gone,  which  is  the  earliest  lost  reflex  in  tabes,  I  be- 
lieve. The  Babinski  sign  was  also  present.  He  had 
the  lack  of  pain  on  deep  pressure  in  the  leg  muscles, 
which  is  rather  characteristic.  His  eyes  were  per- 
fectly normal.  The  knee  reflexes  were  equal,  with 
the  exception,  possibly,  of  only  slight  slowing  in 
the  right  patellar  reflex.  The  laboratory  findings 
in  this  case  were  positive.  He  finally  acknowledged 
having  sores  twelve  years  before  and  had  gone  to 
Hot  Springs  where  they  told  him  there  was  abso- 
lutely nothing  wrong.  He  went  back  a  year  ago 
and  they  told  him  there  was  no  use  taking  the  Was- 
sermann.  On  examination  in  this  case  we  found 
a  4  plus  blood  Wassermann  and  a  4  plus  spinal 
positive.  The  cell  count  was  60  and  the  Gold  solu- 
tion test  was  pronounced  in  3,  4  and  5,  which  gave 
an  absolute  diagnosis  of  tabes.  I  should  like  to 
have  some  one  tell  us  what  to  do. 

Dr.  I.  S.  KoLL,  Chicago:  I  believe  we  have 
a  condition  in  the  bladder  which  we  can  call  the 
luetic  bladder — I  do  not  believe  we  can  say  tabetic. 
In  the  past  two  months  I  have  seen  two  cases  in 
which  it  was  impossible  to  elicit  tabes,  with  4  plus 
Wassermanns,  in  which  rigidity  of  the  ureteral  ori- 
fices was  present.  The  trabeculae  were  of  the  papil- 
lary type.  I  found  what  I  believe  was  a  gumma- 
tous condition  of  the  bladder,  from  the  fact  that 
the  mucous  membrane  had  lost  its  luster,  there  were 
no  blood  vessels  such  as  we  see  in  the  normal 
mucous  membrane,  and  the  tonicity  of  the  bladder 
was  gone.  The  patient  had  incontinence.  The 
tabetic  bladder  is  more  nearly  of  the  type  that  has 
been  described,  and  of  which  I  now  have  a  record 
of  36  cases,  27  of  which  were  reported  at  Philadel- 
phia. The  following  points  should  lead  us  to  make 
a  positive  diagnosis  in  the  absence  of  every  other 
sign  of  beginning  tabes.  Lateral  trabeculation,  fine  in 
character,  in  contradistinction  to  obstructive  trabec- 

113 


ulation  in  prostatic  enlargement  and  stricture;  the 
prominence  of  the  interureteric  area,  and  rigidity 
of  either  one  or  both  ureteral  orifices,  though  this 
latter  point  is  not  absolutely  constant.  I  do  not 
know  how  to  explain  it,  but  I  believe  it  is  some- 
what comparable  to  the  Argyll-Robertson  pupil 
— possibly  a  sclerosis  of  the  blood  vessels  of  the 
ureteral  orifice. 

Dr.  G.  J.  Thomas,  Rochester,  Minn. :  In  the 
Mayo  clinic  we  see  many  spinal  bladders.  We 
have  noted  the  points  just  spoken  of — beginning 
anesthesia  of  the  posterior  urethra  with  relaxation 
of  the  sphincter.  Such  cases  are  sent  to  the  neu- 
rologist who  makes  the  neurologic  tests  and  plats 
out  the  sensation.  He  has  frequently  found  what 
he  considers  early  loss  of  sensation  about  the  peri- 
neum which,  with  the  finding  of  trabeculation  in 
the  bladder,  warrants  a  diagnosis  of  cord  involve- 
ment, which  is  most  often  tabes.  I  recall  one  of 
Dr.  Braasch's  cases  in  which  no  venereal  or  urin- 
ary history  could  be  obtained  that  was  found 
clinically  to  be  a  typhoid  condition  of  the  spine.  In 
this  patient  there  was  the  typical  trabeculation  of 
the  bladder  with  relaxation  of  the  bladder  and 
sphincter.  I  am  sorry  Dr.  Corbus  did  not  say  more 
about  early  syphilis  in  which  he  has  found  a  posi- 
tive spinal  fluid  because  this  is  important  and  he  has 
observed  and  reported  a  large  number  of  such  cases. 

Dr.  B.  C.  Corbus,  Chicago:  I  do  not  deny 
that  there  is  trabeculation  in  tabes  of  the  bladder, 
but  we  cannot  make  it  a  pathognomonic  or  diag- 
nostic sign.  I  find  in  these  cases  without  symptoms 
about  1  in  4  show  spinal  fluid  involvement,  with 
a  negative  blood  Wassermann.  The  idea  is  to  get 
them  before  they  reach  the  tabetic  stage.  Whether 
it  begins  at  the  top  or  bottom  the  achilles  reflex 
can  be  involved.  There  is  where  the  syphilis  be- 
gins, and  may  advance,  or  later  involve  the  bladder, 
but  it  is  all  syphilis,  up  and  down. 

Dr.  H.  L.  Kretschmer,  Chicago:  Trabecula- 
tion of  the  bladder  means  one  of  two  things — either 
obstruction  in  front  of  the  neck  of  the  bladder,  such 
as  a  prostate,  a  stricture,  tumor,  etc,  or  it  means 
an  obscure  lesion  of  the  central  nervous  system.  I 
cannot  agree  with  Dr.  Mark  that  when  you  find 
trabeculation  you  may  make  a  diagnosis  of  tabes 
of  the  bladder.  I  do  not  want  to  cite  personal 
cases,  but  I  have  seen  trabeculation  of  the  bladder, 
for  instance,  in  cases  of  myelitis  and  in  cases  of 
traumatic  injury  to  the  cord.  I  recall  one  man 
who  was  operated  on  for  osteoma  of  the  spine. 
Following  the  operation  he  had  a  hemorrhage  into 
the  cord  with  a  resuUing  paralysis  of  the  bladder 
which  later  showed  very  marked  trabeculation.  One 
man  had  multiple  sclerosis  with  trabeculation  of  the 
bladder.  So  that  when  I  use  the  cystoscope  and 
see  this  fine  trabeculation  without  obstruction  I 
diagnose  some  obscure  lesion  of  the  central  nervous 
system.  Then  I  try  to  find  out  what  type  of  lesion. 
I  think  papers  of  this  kind  bring  out  the  fact,  as  was 

114 


brought  out  yesterday,  that  we  are  a  part  of  the 
entire  realm  of  medicine,  the  entire  realm  of  diag- 
nosis ;  that  we  cannot  attempt  to  diagnose  tabes  by 
looking  through  a  cystoscope;  we  have  got  to  go 
over  the  whole  body.  Dr.  Thomas  says  when  they 
see  these  cases  they  turn  them  over  to  the  neu- 
rologist. In  tabes  one  may  see  an  early  perineal 
anesthesia  and  loss  of  deep  muscular  sensation ; 
so  that  I  do  not  think  the  bladder  condition  is  pri- 
mary; it  is  simply  part  and  parcel  of  the  whole  pic- 
ture. I  should  like  to  know  how  to  recognize  these 
tabetic  bladders.  How  can  we  differentiate  cysto- 
scopically  the  trabeculation  of  tabes,  multiple  sclero- 
sis, myelitis,  etc.  Possibly  the  sign  of  which  Dr. 
Koll  has  spoken— rigidity  of  the  ureteral  orifice 
— would  give  us  some  aid. 
¥  ¥  *  :^  ^if  ;Vi  * 

Symposium  on  Diseases  of  the  Seminal 
Duct. 

Dr.  R.  B.  H.  Gradwohl,  St.  Louis:  I  have 
been  interested  in  Dr.  Belfield's  work  for  some  time. 
My  attention  was  more  particularly  drawn  to  it  by 
an  opportunity  to  have  Dr.  Jost  work  out  these 
cases  with  me.  From  the  standpoint  of  the  bac- 
teriologist I  can  corroborate  what  Dr.  Schmidt  has 
said  in  regard  to  gonorrheal  infection.  In  this 
series  of  about  40  selected  cases  the  organisms 
found  were  staphylococcus  albus ;  in  a  relatively 
small  number  it  was  the  gonococcus  at  the  time 
they  came  for  treatment.  This  was  verified  both 
bacteriologically  and  by  the  complement  fixation 
test.  My  opinion  on  the  value  of  this  method  would 
be  necessarily  more  from  the  standpoint  of  the  lab- 
oratory man  than  that  of  the  surgeon,  but  this 
seems  to  be  a  logical  procedure,  vasostomy  with 
drainage,  in  cases  which  have  resisted  the  ordinary 
medical  measures  by  the  practitioner.  So  far  as 
vaccine  therapy  alone  of  this  class  of  cases  is  con- 
cerned, I  believe  it  is  exceptional  to  find  good  re- 
sults. In  some  cases  we  have  seen  good  results, 
but  it  seems  to  me  this  form  of  therapy,  unaided 
by  surgical  intervention,  has  been  a  great  disap- 
pointment, so  that  the  hope  of  radical  cure  rests 
with  the  surgeon.  Dr.  Jost  will  tell  you  about 
everything  else  we  have  learned  together. 

Dr.  William  E.  Jost,  St.  Louis:  Following 
the  masterly  manner  in  which  Dr.  Belfield  has 
handled  the  subject  of  vasotomy,  there  is  little  left 
for  me  to  say,  yet  it  is  exceedingly  interesting  for 
us  to  review  the  old-time  methods  in  attempting  to 
clear  up  infections  of  the  seminal  tract  and  contrast 
them  with  the  modern  methods  of  today.  The  for- 
mer were  failures;  the  latter  successes.  Dr.  Bel- 
field's  paper  in  December,  1  909,  afforded  us  a  new 
line  of  reasoning  and  made  a  new  angle  of  attack 
on  what  has  proved  to  be  the  hardest  nut  for  the 
neurologist  to  crack,  namely,  infections  of  the  semi- 
inal  vesicle.  The  infections  from  the  gonococcus 
as  well  as  other  seminal  tract  infections  have  until 

115 


the  past  few  years  found  a  fortified  home  in  this 
part  of  the  human  anatomy.  They  have  defied  any 
and  all  attempts  to  cause  their  extermination.  Since 
the  operation  of  vasotomy  opens  up  a  new  avenue  of 
attack,  the  pus  organisms  whose  habitat  was  here- 
tofore located  in  the  seminal  vesicles  have  been 
forced  to  come  in  direct  contact  with  argyrol  eind 
after  a  brief  encounter  were  successfully  repulsed. 
Such  is  the  result  of  relieving  tension  by  drainage 
and  properly  medicating  the  seminal  tract.  It 
is  a  decided  victory  for  the  urologist,  to  say  noth- 
ing of  the  unfortunate  patient.  The  vasostomy  oper- 
ation affords  him  his  formal  release.  I  want  to 
go  on  record  as  being  a  staunch  believer  in  this 
surgico-medical  procedure.  It  is  the  only  known 
recognized  method  to  exterminate  infections  in  the 
seminal  tract,  which  are  in  the  great  majority  gon- 
orrheal. It  becomes  the  duty  of  the  urologist  to 
trace  out  the  etiology  of  many  reflex  conditions,  not 
only  in  the  pelvis,  but  also  in  the  abdomen.  It  is 
surprising  how  many  sources  of  irritation  are  defi- 
nitely traced  to  the  seminal  tract — vesicle,  vas  or 
epididymis.  I  concur  with  Dr.  Belfield's  state- 
ment that  many  cases  of  "irritable  bladder,  chronic 
cystitis,  impotence,  sterility,"  as  well  as  the  various 
neuroses,  are  due  to  prostato-vesiculitis.  I  have 
quite  an  interesting  class  of  such  cases,  who  have 
proved  very  grateful  patients  indeed. 

I  was  attracted  to  vasostomy  by  Dr.  Belfield's 
paper  in  1  909,  because  in  my  hands  all  other  meas- 
ures in  seminal  vesiculitis  had  failed,  in  spite  of  the 
fact  that  there  was  no  encouragement  in  my  medical 
vicinity  in  corroboration  of  Dr.  Belfield's  work. 
At  the  very  beginning  in  trying  it  out  I  was  more 
than  gratified  with  the  results.  The  group  in 
which  I  have  tried  vasostomy  now  numbers  about 
40  cases,  representing  cases  which  had  failed  to 
respond  to  other  forms  of  treatment,  which  had 
been  applied  not  only  by  me,  but  by  others,  con- 
sisting of  massage,  injections,  instillations  and  vac- 
cines, carried  out  over  a  number  of  months,  and  in 
some  cases  years.  In  passing  I  might  state  that 
one  patient  had  been  treated  for  eighteen  years 
without  success  and  was  permanently  relieved  by 
vasostomy. 

In  the  beginning  of  my  experience  some  of  my 
failures  occurred  by  reason  of  the  fact  that  I 
operated  on  but  one  side,  hoping  that  this  would 
suffice,  and  these  patients  later  refusing  a  second 
operation  on  the  other  side.  It  was  impossible  to 
say  whether  the  operation  had  failed  because  the 
wrong  side  had  been  primarily  selected.  After 
adopting  the  method  of  double  operation  at  one 
sitting  I  have  seldom  failed.  Of  course  in  some  of 
these  cases  the  complicating  factor  of  disease  of 
the  verumontanum  had  to  be  attended  to  by  local 
measures.  I  use  Dr.  Belfield's  original  technic,  ex- 
cepting that  I  have  a  skin  hook  bent  at  right  angle 
which  I  slip  through  the  skin  and  under  the  vas 
before  making   the   incision.      I    also   use   a    blunt 

116 


pointed  cannula  in  the  vas  and  permit  it  to  remain 
in  place  by  suturing  it  to  the  skin. 

We  should  look  into  cases  of  impotence  and 
sterility  more  carefully  and  more  energetically,  and 
I  am  satisfied  that  after  proper  surgical  procedure 
on  the  seminal  tract,  together  with  thorough  medi- 
cation of  its  interior,  in  many  cases  the  spermatozoa 
will  resume  their  motility,  regular  form  euid  func- 
tion. It  is  really  surprising  how  many  cases  diag- 
nosed as  lumbago  both  by  the  general  practitioner 
and  the  laity  prove  to  be  in  the  hands  of  the  urologist 
"prostato-vesiculitis."  Some  cases  improve  to  some 
extent  after  massage  of  the  prostate,  but  treatment 
of  both  prostate  and  vesicles  is  imperative.  There 
is  no  doubt  that  the  general  practitioner  allows 
many  cases  of  this  kind  to  go  unrecognized,  and 
consequently  untreated.  "Pus  Tubes  in  the  Male" 
must  be  recognized  as  correct  nomenclature  for  the 
infection  of  this  part  of  the  sexual  apparatus.  At- 
tacking at  or' near  the  inferior  end  of  the  seminal 
tract  to  relieve  tension,  drain  and  medicate  the  in- 
terior, is  certainly  "getting  at  the  bottom  of  things." 
The  synergistic  action  of  vasostomy,  plus  autovac- 
cines,  enables  the  urologist  to  carry  on  a  successful 
warfare  against  the  entrenched  army,  which,  on 
account  of  its  strategical  importance,  has  selected 
the  seminal  vesicle  as  a  base  for  irritative,  toxic  and 
reflex  operations.  It  is  a  clinical  fact  that  the  vesicle 
distends  sufficiently  to  allow  the  injected  medication 
to  come  into  intimate  contact  with  its  interior  before 
the  duct's  sphincter  relaxes  and  allows  the  liquid 
to  escape  through  the  ejaculatory  duct.  This  is 
fortunately  a  very  happy  "order  of  things"  as  the 
medication  remains  in  the  cavity  of  the  seminal  tract 
sufficiently  long  to  be  effectual.  It  is  amusing  to 
listen  to  the  patient  tell  of  his  nocturnal  ejaculation 
of  argyrolized  seminal  vesicle  contents. 

My  case  records  show  that  the  procedure  of 
vasostomy,  supplemented  by  proper  injections  of 
argyrol,  vanquishes  the  majority  of  these  infections. 
Before  Dr.  Belfield  announced  his  successful  explor- 
ation of  this  secretory  canal,  its  peculiar  anatomical 
position  and  the  utter  impossibility  of  medicating  its 
interior,  guaranteed  failure  and  disappointment  in 
the  attempt  to  eradicate  this  disease,  long  baffling 
the  medical  man  and  producing  dissatisfied  and 
disheartened  patients. 

Dr.  W.  E.  Lower,  Cleveland,  Ohio:  This 
symposium  on  the  seminal  vesicles  has  been  most 
interesting  to  me.  The  anatomy  of  these  structures 
has  been  beautifully  demonstrated,  and  also  the  al- 
ready well-standardized  operative  procedures  upon 
these  organs.  After  seeing  the  picture  shown  by 
Dr.  Smith,  however,  I  am  not  quite  sure  that  sim- 
ple drainage  is  going  to  be  sufficient  to  relieve  many 
of  these  cases,  but  wonder  if  we  must  not  expose 
the  entire  seminal  vesicle  and  ferret  out  all  the 
pockets  and  drain  them.  The  evidence  by  which 
this  procedure  is  going  to  be  measured  will,  of 
course,   be  the   clinical   results.      These   operations 

117 


have  now  been  practiced  for  a  sufficient  length  of 
time  for  the  results  to  be  carefully  tabulated.  If 
the  American  Urological  Association  would  ask 
for  end  results  in  these  cases  we  should  know 
whether  or  not  we  are  getting  the  relief  which  we 
are  seeking.  We  must  know  whether  these  pa- 
tients are  permanently  benefited  and  what  are  the 
post-operative  complications.  If  the  end  results 
are  going  to  be  as  good  as  they  seemed  to  be  from 
early  reports,  we  have  certainly  made  a  great  ad- 
vance and  have  found  a  procedure  which  we  may 
well  hope  will  clear  up  many  of  these  difficult  and 
annoying  cases.  After  all  we  must  not  deceive  our- 
selves, or  let  our  enthusiasm  in  operative  technic 
blind  us  to  the  postoperative  results. 

Dr.  E.  G.  Mark,  Kansas  City,  Mo.:  We 
have  done  somethmg  like  150  vasostomies,  and  in 
practically  all  cases  we  have  had  good  results  ex- 
cept in  those  cases  in  which  we  used  too  high  a 
percentage  of  silver  salts.  It  has  occurred  to  me 
that  we  strike  so  many  of  these  cases  in  which  the 
duct  is  not  patent,  and  if  it  is  not  patent  what  is 
going  to  happen  under  the  injection  of  a  silver  salt 
or  any  other  fluid  in  the  vas,  as  Dr.  Belfield  has 
said,  must  occur,  and  the  same  thing,  it  seems  to 
me,  would  occur  with  a  vesiculotomy.  If  you  do 
a  vesiculotomy  with  a  stenosed  ejaculatory  duct 
you  are  going  to  have  continuous  drainage  from 
that  vesicle.  I  believe  that  marks,  to  a  certain  de- 
gree, the  turning  point  in  vesiculotomy  and  vesiculec- 
tomy. That  has  in  a  marked  degree,  except  in 
fibrosis,  determined  our  choice  between  vesiculo- 
tomy and  vesiculectomy  and  we  have  in  no  way 
been  influenced  by  impotency. 

With  reference  to  Dr.  Staley's  paper  regarding 
epididymotomy,  one  who  has  studied  the  anatomy 
of  the  epididymis  must  know  that  when  he  plunges 
a  knife  into  the  epididymis  he  practically  short 
circuits  the  whole  thing,  so  that  the  testicle  must  be 
sterile  on  that  side.  Whether  there  is  pus  there  or 
not,  if  one  could  by  a  careful  dissection  go  down 
and  simply  relieve  the  tension  caused  by  the  bind- 
ing down  of  the  fascia  one  would  do  good,  but  if 
we  attempt  to  make  a  puncture  in  the  epididymis  or 
to  split  the  epididymis  we  are  going  to  do  more  harm 
than  good. 

Dr.  V.  D.  LesPINASSE,  Chicago:  I  am  sorry 
Dr.  Sanford  misunderstood  me.  The  epididymis 
is  one  continuous  tube  and  there  are  no  blind  chan- 
nels at  all,  but  one  tube  coiled  up  in  a  number  of 
pockets,  with  connecting  tubes  between  the  ad- 
joining pockets.  In  epididymitis  the  distension  is 
so  great  that  the  tubes  are  in  contact  with  the  cap- 
sule, and  in  blind  stabs  you  are  almost  sure  to  cut 
the  tubules.  If  you  try  to  dissect  out  the  epididymis 
and  show  the  complete  anatomy  it  is  very  difficult 
to  remove  the  capsule  and  not  cut  the  tubules.  So 
I  should  warn  any  one  who  tries  to  perform  an  epi- 
didymotomy to  certainly  expose  the  epididymis,  and 
in  cutting  down  through  the  fascial  layers  to  exercise 

118 


great  care  as  they  approach  close  to  the  tubules 
so  as  not  to  cut  them.  When  one  is  down  close  to 
the  capsule  push  a  forceps  in  and  separate  the  struc- 
tures then  with  a  director  hold  the  tubules  back 
and  snip  the  capsule.  A  blind  stab  with  a  knife 
into  the  epididymis  is  very  risky.  With  a  needle 
it  is  not  so.  With  a  needle  you  can  go  in  for 
various  purposes,  and  I  do  not  think  the  tubules 
close  up  after  puncture  with  a  fine  needle,  although 
I  have  no  absolute  evidence  as  to  this. 

Dr.  G.  J.  Thomas,  Rochester,  Minn. :  We 
have  seen  a  few  cases  of  what  we  considered  to  be 
primary  tuberculosis  in  the  prostate  in  which  we 
were  unable  to  demonstrate  lesions  in  the  epididymis 
or  kidneys.  In  a  case  now  under  observation  the 
prostate  feels  tuberculous ;  tubercle  bacilli  and  pus 
have  been  found  in  the  urine.  Repeated  examinations 
of  urine  from  the  kidneys  have  shown  no  organisms, 
and  guinea-pig  inoculation  has  been  negative.  The 
pyelographic  outline  seems  to  be  normal  in  both 
kidneys  and  there  is  equal  function.  This  case 
w'ould  appear  to  be  one  in  which  we  can  be  fairly 
sure  of  primary  tuberculosis  in  the  prostate.  At 
the  present  time  the  man  has  no  other  tuberculous 
lesions. 

Dr.  F.  R.  Charlton,  Indianapolis:  I  am 
pleased  that  the  question  of  epididymotomy  has 
taken  the  course  it  has  in  the  discussion.  I  have 
been  rather  loath  to  express  myself  about  epididy- 
motomy for  fear  of  expressing  too  radical  disagree- 
ment. It  is  an  operation  as  old  as  surgery,  and  yet 
it  comes  into  vogue  in  the  last  few  years  with  a 
name  and  a  fame  which  it  seems  to  me  are  utterly 
unwarranted.  After  all  is  said  and  done,  the  pro- 
cedure is  nothing  but  the  puncture  of  an  abscess. 
You  may  discuss  punctilios  as  to  the  question  of 
drainage  but  surgeons  in  our  grandfathers'  time 
punctured  these  abscesses  and  drained  them.  I  re- 
member some  of  the  first  minor  surgical  cases  of 
this  sort  that  I  ever  saw  were  to  all  intents  and  pur- 
poses epididymotomies.  It  has  always  seemed  to 
me  to  be  vicious  practice,  except  when  done  to  re- 
lieve extensive  pockets  of  pus,  and  has  never  seemed 
to  be  warranted  except  for  such  a  condition.  I  am 
perfectly  willing  that  the  patient  should  undergo 
some  pain  for  a  few  days  if  in  the  end  he  might  get 
complete  resolution,  and  you  do  get  complete  resolu- 
tion in  many  cases  of  epididymitis.  I  have  been 
able  to  examine  the  expressed  contents  of  the  vesi- 
cles in  perhaps  half  a  dozen  cases  in  which  there 
had  been  a  vicious  double  epididymitis,  and  have 
found  spermatozoa  in  several  of  that  series  of  cases. 
Dr.  Edward  Martin,  of  Philadelphia,  some  years 
ago  reported  on  this.  I  heard  him  say  years  ago 
that  he  had  demonstrated  active  spermatozoa  afier 
vicious  double  epididymitis.  That  being  the  case, 
the  situation  is  not  hopeless  at  all.  The  patient 
certainly  has  a  very  good  chance  of  retaining  his 
potency  after  an  acute  attack  of  single  or  double 
epididymitis.     When  you  do  an  epididymotomy  you 

119 


sterilize  the  individual.  I  am  satisfied  if  you  cut 
deep  into  the  capsule  you  cannot  help  but  do  it. 
And  feeling  in  that  mood  about  the  situation,  I 
have  never  done  an  epididymotomy  except  to  re- 
lieve extensive  pus  infiltration.  I  do  not  believe  it  is 
good  practice  except  in  such  advanced  abscess  cases. 

Dr.  E.  G.  Mark,  Kansas  City:  Dr.  Les- 
pinasse,  would  it  not  be  a  good  idea  in  cases  with 
extreme  pain,  and  in  the  cases  Dr.  Charlton  speaks 
of,  to  loosen  up  the  capsule  and  relieve  the  tension? 
For  that  is  where  we  are  getting  the  pain. 

Dr.  Charles  M.  McKenna,  Chicago,  111.: 
The  question  that  Dr.  Marks  has  asked  is  the  key 
to  the  situation.  I  do  not  think  that  in  doing  an 
epididymectomy  the  pathology  of  the  epididymis 
alone  should  be  considered.  It  will  be  remembered 
that  on  doing  this  operation  the  various  fascias  about 
the  epididymis  and  testis  are  involved  and  the  ten- 
sion brought  on  these  various  fascias  gives  the  pa- 
tient a  tremendous  amount  of  pain.  Upon  making 
an  incision  through  the  layers  of  fascia  to  the  epi- 
didymis proper  this  tension  is  relieved,  and  as  a  re- 
sult the  patient  will  rest  more  comfortably. 

Now  as  to  the  question  of  making  the  patient 
impotent :  I  think  this  is  considered  by  many  from 
a  different  point  of  view.  As  the  other  gentleman 
has  said,  "A  blind  stab  might  cause  an  impotency." 
Of  course  it  would,  because  he  cannot  see  the 
anatomical  structures  involved.  I  agree  with  the 
gentleman  in  that  statement.  However,  if  after  a 
careful  dissection  is  made  down  to  the  epididymis 
and  the  different  fascias  are  separated  from  each 
other  and  from  the  testes  and  epididymis,  the  epi- 
didymis proper  is  in  plain  view ;  then,  if  with  a  fine 
pointed  bistoury  a  small  incision  is  made  in  the  an- 
terior wall  of  the  epididymis  and  a  gutta  percha 
drain  inserted,  the  smaller  tubules  leading  from  the 
testes  will  not  be  destroyed,  thus  rendering  the  pa- 
tient less  apt  to  be  made  impotent  than  if  the  condi- 
tion were  left  to  be  absorbed  by  nature.  In  my  last 
two  cases  I  have  made  a  dissection  and  separated 
the  fascias,  with  very  gratifying  results. 

Conclusion. — I  think  if  this  method  were  carried 
out  more  extensively,  even  without  making  incisions 
in  the  epididymis,  better  results  would  be  had. 
After  all,  this  operation  is  done  to  relieve  the  pa- 
tient of  pain. 

Dr.  I.  S.  KoLL,  Chicago:  A  point  in  diagnosis 
in  connection  with  the  masterly  presentation  by  Dr. 
Plaggemeyer  I  think  is  worthy  of  emphasis,  namely, 
the  differential  diagnosis  between  chronic  inflamma- 
tory conditions  of  the  epididymis  and  tuberculosis 
of  the  epididymis.  In  the  past  year  and  a  half  I 
have  seen  six  cases,  two  of  which  were  in  Dr. 
Schmidt's  service  at  the  Michael  Reese  Hospital, 
in  which  clinically  there  was  every  indication  of 
tuberculosis  of  the  epididymis.  I  had  seen  four 
cases  previously,  and  was  keenly  interested  to  know 
what  the  pathologist  was  going  to  say.  Serial  sec- 
tions were  made  from  the  entire  gland  and  no  evi- 

120 


dence  of  tuberculosis  was  found,  but  chronic  inflam- 
mation due  to  the  pyogenic  organisms.  The  four 
other  cases  presented  the  same  type  of  lesion.  In 
three  of  them  cultures  were  positive — one  of  the 
streptococcus  and  two  of  staphylococcus.  I  think 
this  point  is  of  particular  importance  in  regard  to 
our  postoperative  treatment,  besides  relieving  the 
mind  of  the  patient  of  the  possibility  of  his  having 
a  recurrence  of  a  tuberculous  condition.  I  believe 
in  a  certain  percentage  of  these  cases  it  is  impos- 
sible to  make  a  definite  diagnosis  of  tuberculosis 
until  the  microscope  has  proved  it  to  be  that. 

Dr.  J.  W.  MaRCHILDON,  St.  Louis:  Some 
years  ago  m  Berlin  I  ran  across  a  case  at  necropsy 
of  infection  of  the  seminal  vesicles  with  the  typhoid 
bacillus,  and  at  the  same  time  a  second  case  of  in- 
fection of  the  prostate  with  typhoid.  These  cases 
were  worked  up  at  that  time  and  reported  from  the 
standpoint  of  typhoid  bacillus  carriers,  and  espe- 
cially as  an  example  of  the  source  of  .infection  of 
the  urinary  bladder  in  those  cases  in  which  infection 
repeatedly  takes  place  with  the  typhoid  bacillus. 
We  had  always  thought  the  gall  bladder  was  the 
ordinary  place  to  harbor  the  typhoid  bacillus.  These 
cases  showed  the  possibility  of  the  prostate  and 
seminal  vesicles  carrying  the  typhoid  organism  and 
reinfecting  the  urinary  bladder  thereafter.  We 
know  that  the  seminal  vesicles  and  the  prostate  are 
prone  to  carry  for  years  other  organisms,  such  as 
the  gonococcus,  the  staphylococcus,  etc. 

Dr.  F.  W.  Robbins,  Detroit:  Three  things 
I  want  to  say.  The  first  is  to  congratulate  the  so- 
ciety on  this  symposium,  which  to  me  has  been  most 
interesting.  The  second  is  to  try  to  emphasize  what 
Dr.  KoU  has  said  about  the  relation  between  chronic 
epididymitis  and  tuberculosis  of  the  epididymis. 
I  have  seen  cases  of  that  kind  that  gave  me  a  good 
deal  of  unhappiness  for  some  length  of  time,  and 
others  in  which  after  being  as  careful  as  possible 
I  have  come  to  the  conclusion  that  tuberculosis  was 
not  present,  but  chronic  epididymitis.  I  have  noticed 
that  most  all  books  on  urology  have  mighty  little  to 
say  about  chronic  epididymitis.  In  regard  to  opera- 
tions on  the  vesicle,  to  my  mind  it  is  often  so  diffi- 
cult to  separate  entirely  prostatic  from  vesicle  con- 
ditions that  I  am  sure  I  make  mistakes  sometimes, 
and  I  think  if  I  operate  on  the  vesicles  when  I  think 
they  ought  to  be  operated  on,  I  once  in  awhile  won't 
get  improvement  because  the  trouble  primarily  is  in 
the  prostate. 

Dr.  H.  L.  Kretschmer,  Chicago:  I  was 
glad  to  hear  Dr.  Belfield's  remark  about  relapses 
after  epididymotomy.  In  the  large  number  of  ar- 
ticles on  epididymotomy  one  reads  the  statement  that 
relapses  do  not  occur ;  that  they  cannot  recur.  I 
have  not  seen  as  many  cases  as  Dr.  Belfield,  but 
I  have  seen  two  cases,  operated  elsewhere,  in  which 
the  patients  had  a  relapse  on  the  same  side  after 
the  epididymotomy.  Another  had  a  bilateral  epi- 
didymotomy with  recurrence  on  one  side.      I  thmk 

121 


both  Dr.  KoU  and  Dr.  Robbins  made  welcome 
statements.  A  great  many  times  I  have  had  trouble 
in  making  a  differentiation  between  epididymitis 
and  tuberculosis  of  the  epididymis.  I  am  glad  I 
am  not  the  only  one  who  cannot  make  it.  I  think 
the  point  of  Dr.  KoU  as  to  prognosis  is  significant. 
To  say  to  a  patient  that  you  have  operated  for 
tuberculosis  of  the  epididymis,  or  that  he  has  such 
trouble,  is  putting  something  over  him  which  is  not 
very  pleasant.  With  Dr.  Robbins  I  believe  whether 
we  do  a  vesiculectomy  or  a  vesiculotomy,  the  rem- 
nants in  the  prostate  must  receive  due  consideration. 
The  illustrations  so  ably  presented  by  Dr.  Smith 
have  impressed  me  with  this  query :  Will  vesiculo- 
tomy cure  these  patients?  Personally  I  doubt  it.  If 
we  are  going  to  subject  these  patients  to  operation 
it  should  be  a  vesiculectomy. 

Dr.  E.  O.  Smith,  Cincinnati:  The  subject 
of  calculi  in  the  seminal  vesicles  has  been  referred 
to.  I  am  sorry  that  Dr.  Lewis  is  not  here  to  give 
us  his  observations  on  the  subject,  for  the  reason 
that  in  the  large  number  of  these  postmortem  speci- 
mens that  I  have  examined  and  in  the  limited  num- 
ber of  vesiculotomies  I  have  performed,  no  calculus 
has  been  found.  There  is  no  reason  why  they 
should  not  be  there.  They  are  frequent  in  the  gall 
bladder,  but  we  are  still  looking  for  them  in  the 
seminal  vesicle. 

The  question  of  where  we  shall  draw  the  line 
between  patients  who  should  be  operated  on  and 
those  who  should  not  be  operated  on  is  of  course 
still  in  dispute.  After  some  little  experience  in  a 
surgical  way,  I  would  not  undertake  a  case  unless 
it  presented  pus  or  chronic  arthritis,  and  then  only 
after  all  other  methods  had  been  used  and  had 
failed.  Last  May  we  had  a  case  that  Dr.  Keller 
saw  us  do  a  drainage  operation  on.  The  patient 
had  had  all  kinds  of  treatment  for  a  period  of  three 
years.  One  year  of  this  time  he  was  in  my  hands. 
His  experience  before  the  operation  was  like  this: 
He  had  frequent  nocturnal  emissions,  as  many  as 
three  in  a  night,  and  as  many  as  five  nights  a  week. 
This  was  not  pleasant  or  satisfactory  to  him,  so  he 
would  go  out  once  in  awhile,  even  ^vith  this  ex- 
cessive drainage,  and  have  intercourse.  After  each 
intercourse  he  would  have  free,  copious  discharge 
of  yellow  pus  from  the  urethra.  We  decided  to 
drain  him  and  are  pleased  to  report  that  the  pa- 
tient has  had  absolutely  no  trouble  since — no  ab- 
normal frequency  of  emissions  and  no  pus.  We 
believe  that  the  time  has  been  long  enough  to  say 
that  he  is  cured.  In  neurasthenic  or  impotent  pa- 
tients I  would  hesitate  to  operate  as  recommended 
by  Fuller. 

I  think  the  slides  I  presented  demonstrate  con- 
clusively that  simple  incision,  particularly  in  the 
lower  part  of  the  vesicle,  will  do  but  little  good. 
Most  of  the  retained  pus  is  found  in  the  upper  part 
of  the  vesicle,  in  saccules,  all  of  which  cannot  be 

122 


drained  by  simple  incision,  but  require  multiple  in- 
cisions. 

Before  doing  this  operation  on  a  living  patient,  I 
did  it  several  times  on  a  cadaver,  and  would  recom- 
mend this  same  preparation  to  any  who  contemplate 
vesiculotomies.  The  male  perineum  is  a  complex 
anatomical  structure  in  which  one  can  easily  lose 
his  bearings. 

The  position  of  the  patient  is  important.  He 
should  be  in  the  extreme  lithotomy  position,  the 
knees  well  flexed  on  the  abdomen.  In  this  position 
the  perineum  is  put  on  the  stretch  and  dissection  is 
more  easily  made  without  damage  to  the  rectum  or 
bladder. 

Dr.  R.  W.  Staley,  Cincinnati:  I  am  afraid 
we  are  getting  mixed  up  about  epididymotomy.  The 
contention  seems  to  be  that  in  endeavoring  to  drain 
the  pus  pocket  in  the  epididymis,  there  is  danger 
of  entirely  severing  one  or  more  convolutions  of  the 
vas,  thus  bringing  about  a  one-sided  sterility.  Epi- 
didymotomy is  a  delicate  procedure  and  one  should 
not  haggle  and  blunder  around  indiscriminately  or 
the  continuity  of  the  vas  will  be  destroyed  sure 
enough.  The  main  feature  of  the  operation  is  the 
incision  of  the  tunica  for  the  relief  of  tension.  All 
intraepididymal  probing  should  be  done  with  blunt 
instruments.  Recurrences  of  epididymitis  in  organs 
which  have  had  the  operation  seem  to  me  to  point 
to  one  of  two  things;  either  the  drainage  was  not 
thorough  enough  and  a  focus  of  infection  was  left 
which  later  on  flared  up,  or  else  reinfection  from 
the  vesicle  or  posterior  urethra  occurred  which  would 
tend  to  prove  that  the  integrity  of  the  vas  had  been 
preserved. 

Dr.  W.  T.  BeLFIELD,  Chicago:  The  branch- 
ing culs-de-sac  or  diverticula  of  the  seminal  vesicles, 
shown  in  Dr.  Smith's  photographs  and  in  Roent- 
genograms of  the  injected  vesicles  that  I  have  pub- 
lished, explain  many  failures  to  eradicate  non-tuber- 
culous infections  of  the  vesicles  by  massage,  even 
by  vasostomy  and  vesiculotomy.  It  can  hardly  be 
expected  that  a  simple  incision  into  the  lower  end 
of  the  vesicle  will  drain  and  clean  these  culs-de-sac 
of  the  upper  part.  Hence,  it  would  seem  that  after 
the  failure  of  massage  cuid  of  vasostomy  has  been 
demonstrated  in  a  given  case,  further  operative 
therapeutics  should  contemplate  the  excision,  rather 
than  the  incision  of  the  vesicle.  Whether  this  is 
surgically  wise  must  be  determined  by  larger  ex- 
perience. 

Dr.  Louis  E.  Schmidt,  Chicago:  In  refer- 
ence to  what  Dr.  Lower  said  about  excising  the 
vesicles,  in  some  instances  it  is  probably  the  correct 
procedure,  but  not  in  all  instances,  because  many 
vesicles  are  tubular.  Then  a  fair  percentage  are 
connected  with  diverticula.  In  both  instances  this 
morning  I  opened  up  the  fascia,  opened  the  vesicles 
and  put  the  forceps  into  the  vesicles  showing  that 
they  were  like  a  tube  and  not  convoluted.  There 
have  been  instances  in  my  experience  in  which  it 

12:3 


has  been  absolutely  necessary  to  open  the  fascia, 
expose  the  vesicles  thoroughly  and  make  incisions 
into  the  vesicles  and  into  the  diverticula,  as  has  been 
advised. 

As  far  as  the  results  of  vesiculotomy  and  vesicu- 
lectomy are  concerned,  I  think  the  reports  of  Fuller 
and  Squier,  and  I  know  particualrly  my  own,  are 
not  of  such  a  character  as  to  make  me  believe,  or 
anybody  else  believe,  that  it  is  going  to  be  a  uni- 
versal operation.  But  if  after  routine  treatment, 
then  vasostomy,  and  you  are  positive  the  vesicle  is 
the  real  focus,  I  am  under  the  impression  that  it  is 
desirable  to  consider  the  operative  procedure  on 
the  vesicle.  So  far  as  the  details  are  concerned, 
there  will  vary  in  individual  cases.  I  agree  with 
Dr.  Belfield  in  removing  the  vesicles  if  the  wall  is 
particularly  well  infiltrated  or  if  you  are  dealing 
with  a  vesicle  of  a  type  in  which  drainage  is  not 
sufficient.  But  if  you  open  a  pseudo  abscess  or 
drain  an  abscess  of  any  kind  for  a  definite  length  of 
time,  it  certainly  gives  opportunity  for  resorbing  of 
the  deposit  and  the  making  of  a  recovery. 

Dr.  E.  O.  Smith,  Cincinnati:  Mr.  Chairman, 
I  believe  I  express  the  sentiment  of  all  the  guests 
when  I  say  we  would  like  to  extend  a  vote  of  thanks 
to  the  Chicago  Association  for  the  most  excellent 
manner  in  which  they  have  taken  care  of  us. 

A  motion  to  this  effect  carried. 


124 


THE  BIO-CHEMISTRY  OF  THE  GONO- 

COCCUS   IN   ITS  RELATION 

TO  IMMUNITY.^  *^ 

By  Cari.  C.  Warden,  M.  D.,  Ann  Arbor,  Mich. 

Gonococcus  substance  as  obtained  from  culture 
yields  on  analysis  about  I  2  per  cent,  nitrogen,  or 
the  equivalent  of  75  per  cent,  protein,  about  20 
per  cent,  fat,  together  with  phosphorus,  sulphur, 
salts  and  ash.  The  analysis  varies  somewhat  with 
the  amount  of  water  contained  in  the  sample,  and 
the  character  of  the  medium  on  which  the  germs 
are  grown.  Washing  invariably  removes  nitrogen 
and  fat,  and  it  is  probable  that  the  presence  of 
carbohydrate  m  the  medium  increases  the  quantity 
of  fats. 

The  gonococcus  possesses  at  least  three  enzymes, 
one  proteolytic  acting  best  in  an  alkaline  medium, 
another  hydrolytic,  splitting  dextrose,  and  another, 
a  lipase  which  hydrolyses  fats.  Each,  doubtless 
is  reversible  in  action.  These  enzymes  vary  in 
amount  with  the  medium  employed  for  culture,  the 
sugar  splitting  ferment,  for  example,  being  in- 
creased in  the  presence  of  dextrose. 

The  body  of  the  gonococcus  is  exceedingly  soft, 
easily  injured  mechanically  and  very  pervious  to 
water.  The  limiting  membrane  must  be  extremely 
delicate  and  contain  little  or  no  protective  substance 
of  wcixy  or  fatty  nature,  since  the  Gram  stain  is 
invariably  lost.  This  organism,  with  the  meningo- 
coccus, appears  to  stand  in  body  hardness  at  the 
extreme  end  of  the  coccaceae  family  whose  most 
hardy  members  are  found  in  some  of  the  varieties 
of  staphylococcus.  The  gonococcus  contains  prac- 
tically no  cholesterol-like  substance  (phytosterol) 
of  which  the  hardiest  and  best  protected  organisms 
like  the  tubercle  bacillus  contain  large  quantities. 

It  has  long  been  a  matter  of  common  observa- 
tion that  gonococci,  or  meningococci,  after  having, 
been  suspended  in  water  or  salt  solution,  ultimately 
disappear  entirely, — in  other  words  undergo  what 
is  known  as  autolysis,  unless  preserved  by  heat  or 
chemicals,  as  in  the  preparation  of  vaccines.  This 
"habit"  of  autolysis  is  the  most  conspicuous  and 
constant  feature  of  these  organisms.  The  mechanics 
of  autolysis  is  at  once  very  simple  and  highly  com- 
plex; simple  in  that  it  is  always  set  in  motion  in 
presence  of  excess  of  water,  whether  the  excess  be 
in  culture  medium,  in  vitro,  or  in  animal  body  fluids, 
— complex  in  the  number  of  factors  at  work.  Of 
these  factors  may  be  mentioned  alterations  of  sur- 
face energy  leading  to  edema  and  rupture,  the  cata- 
lytic effects  of  H  and  OH  ions  in  the  excess  of 
water,  of  amino  acids  derived  from  the  cocci  them- 


*Read    at    the    Joint    Meeting    of    the    Chicago    Medical 
and    Urological    Societies,    January    5,     1916. 

**From    the    Hygienic    Laboratory,    Univ.    of    Michigan. 


[Reprinted    from    THE   UROLOGIC  AND    CUTANE- 
OUS  REVIEW,    April,    1916.] 

125 


selves,  and  of  enzymes.  The  process  is  hastened 
by  moderate  temperatures,  up  to  60,  and  by  alka- 
hes,  and  is  checked  by  extremes  of  temperature  and 
by  mineral  acids.  Autolysis  of  the  gonococcus  is 
accompanied  not  only  by  disintegration  of  the  body 
of  the  coccus  and  liberation  into  the  menstruum  of 
its  products  of  metabolism,  but  also  by  hydrolysis, 
a  chemical  splitting  of  its  components,  especially 
its  protein,  so  that  there  may  be  observed  in  the  fluid 
at  one  time  or  another  proteoses,  peptone,  amino 
acid  and  so  on  through  the  list  of  nitrogen  deriva- 
tives to  NH  3,  (ammonia).  The  rapidity  and 
completeness  of  the  process  depend  in  a  measure 
upon  excess  of  water,  temperature,  time,  enzyme 
concentration,  etc.  In  the  sera  of  laboratory  ani- 
mals and  man  a  suspension  of  gonococci  undergoes 
autolysis  and  at  the  same  time  induces,  by  colloidal 
absorption,  toxicity  in  the  sera  in  a  manner  similar 
to  other  colloids.  An  aqueous  or  normal  salt  sus- 
pension of  gonococcus  behaves,  physically,  as  a 
colloid  with  an  electro-negative  sign,  and  is  floc- 
culated or  agglutinated  by  electrolytes  of  opposite 
sign,  and  by  other  colloids,  such  as  serum,  under 
certain  conditions. 

Clinical  experience  with  gonococcus  infections 
has  demonstrated  that  the  treatment  of  the  disease 
by  vaccines  as  ordinarily  prepared  is  disappointing. 
From  some  of  the  above  facts  it  may  be  inferred 
that  such  vaccines  may  not  contain  the  germ  sub- 
stance as  it  exists  when  alive  in  culture  or  in  the 
body,  or  in  a  condition  to  induce  antibody  forma- 
tion by  subcutaneous  injection.  This  supposition  is 
in  part  supported  by  the  fact  that  the  administra- 
tion of  vaccine  or  antigen  does  not  produce  in  the 
serum  of  the  patient  or  normal  individual  such  sub- 
stances or  antibodies  as  will,  in  the  presence  of  emti- 
gen,  fix  complement.  In  other  words  the  administra- 
tion of  a  dose  of  vaccine  does  not  produce  a  posi- 
tive complement-fixation  test.  With  these  ideas 
in  mind  I  endeavored  to  improve  gonococcus  vac- 
cines by  first  cultivating  the  cocci  free  from  auto- 
lysis and  subsequently  suspending  them  in  a  non- 
autolysing  menstruum.  I  found  that  in  anhydrous 
substances  such  as  pure  glycerol  and  oil  the  cocci 
could  be  kept  alive  for  a  considerable  period  and 
preserved  intact  indefinitely,  but  my  experiments 
on  animals  and  man  with  these  stable  vaccines, 
with  both  alive  and  dead  organisms,  showed  them 
to  be  no  more  curative  or  antibody  forming  than  the 
old.  Live  and  dead  organisms  alike  promptly  un- 
derwent autolysis  in  the  body  fluids  following  in- 
oculations. The  injections  led  to  severe  local  re- 
actions cimounting,  in  some  instances,  to  sterile  ne- 
croses and  to  general  symptoms  to  be  classed  among 
anaphylactic  phenomena. 

It  was  assumed  from  the  foregoing  that  the  gono- 
coccus substance,  presumably  its  protein,  which  we 
have  regarded  as  the  antibody  producing  substance, 
or  antigen,  is  not  available  either  in  association  with 
the   disease  itself — there  being   practically   no   im- 

126 


munity  conferred  by  an  attack — or  by  the  methods 
of  vaccine  administration  as  we  know  them.  I  had, 
therefore,  to  approach  the  question  from  a  different 
side.  In  exajninmg  various  suspensions  of  gono- 
coccus,  vaccines,  laboratory  and  commercial  "an- 
tigens," etc.,  it  appeared  that  while  the  nitrogenous 
content  varied  widely,  other  substances  liberated 
in  autolysis  appeared  to  be  more  stable.  These 
were  the  fats,  their  esters  and  acids.  To  determine 
whether  they  exercised  a  function  in  the  phenomenon 
of  complement-fixation  I  separated  the  fats  as  wholly 
and  carefully  as  possible  from  the  gonococcus  sub- 
stance, and,  dissolving  the  product  in  absolute  al- 
cohol, used  the  solution  as  antigen  in  the  test.  The 
results  of  several  hundred  tests  showed  the  solu- 
tion to  give  a  higher  percentage  of  positive  reac- 
tions, and  with  less  fluctuation,  in  gonococcal  infec- 
tions and  suspected  cases  than  the  watery  antigens 
of  commerce,  while  in  no  instance  was  a  positive  re- 
action obtained  with  the  serum  from  a  normal  in- 
dividual or  from  a  patient  with  disease  other  than 
gonorrhea.  At  this  point  it  may  be  said  that  the 
question  whether  such  antigen  may  or  may  not  con- 
tain small  amounts  of  protein,  nitrogen  "rests,"  need 
not  at  the  present  concern  us.  It  was  inferred  from 
the  experience  above  stated  that  the  complement 
binding  power  of  watery  antigen  was  due,  at  least 
in  part,  to  the  presence  of  similar  fatty  substances. 
The  next  phase  of  the  problem  involved  determin- 
ing whether  the  injection  of  the  lipoidal  antigen  into 
the  body  would  exert  any  influence  on  the  course 
of  the  disease,  and  whether  injection  into  a  normal 
individual  would  lead  to  fixation  of  complement. 
Neither  of  these  questions  has  been  fully  worked 
out.  All  that  can  be  said  at  the  present  time  is 
that  with  doses  not  exceeding  1  5  mg.  the  lipoidal 
substcinces,  injected  subcutaneously  in  oil,  have 
shown  a  decided  influence  in  shortening  the  attack, 
while  in  the  early  stages  of  acute  attacks  and  in 
the  chronic  stages  their  influence  has  often  been  im- 
mediate. A  discussion  of  the  role  of  gonococcus 
fats  in  immunity  will  be  referred  to  a  later  paper. 


127 


GONORRHEAL    COMPLEMENT    FIXA- 
TION TEST.* 

By   V.    D.   Lespinasse.    M.   D.,   Chicago,   111. 

This  test,  developed  clinically  by  Swartz  and 
McNeill,  is  a  real  Bordet  and  Gengou  phenomena. 
The  technique  of  the  test  requires  a  few  minims  of 
blood  serum;  it  is  best  to  obtain  from  one  to  five 
c.c.  of  blood  in  a  sterile  test  tube,  let  it  stand  over 
night  and  in  the  morning  the  serum  is  avaliable. 
Any  hemolytic  system  can  be  used.  The  antigen 
used  is  autolized  gonococcus  bodies,  or  perferably 
the  fats  extracted  from  the  gonococcus  according  to 
Warden's  method.  The  test  in  its  essentials  is  car- 
ried out  in  the  same  way  as  a  Wassermann  reaction. 

The  test  appears  in  from  three  to  six  weeks  after 
the  onset  of  the  disease.  In  very  mild  cases,  where 
the  involvement  is  limited  to  the  anterior  urethra, 
or  to  a  small  portion  of  the  anterior  urethra,  the 
test  may  never  appear.  The  metastatic  complica- 
tions of  gonorrhea  give  the  highest  percentage  of 
positive  reactions.  Chronic  posterior  urethritis,  pros- 
tatitis, seminal  vesiculitis,  all  give  the  test  in  a 
goodly  percentage  of  cases. 

The  clinical  value  of  the  test  is  considerable;  it 
is  less  than  the  value  of  the  Wassermann  reaction, 
but  in  certain  types  of  cases  it  is  indispensable.  It 
is  the  only  method  by  which  we  can  tell  whether 
a  given  attack  is  a  newly  acquired  infection,  or  is 
an  acute  exacerbation  of  an  old  trouble.  This  is 
determined  in  the  following  way:  Blood  is  taken 
and  the  test  made,  say  one  week  after  the  onset  of 
the  discharge ;  the  test  comes  positive,  and  we  know 
then  this  attack  is  an  acute  exacerbation  of  an  old 
infection,  for  the  simple  reason  that  one  week  is  too 
short  a  time  for  sufficient  antibodies  to  be  developed 
in  the  blood  serum  to  give  the  test.  The  test  should 
be  made  on  all  candidates  for  marriage,  when  of 
course  we  expect  to  obtain  a  negative.  If  the  test 
comes  positive  and  is  confirmed  by  another  positive, 
then  we  should  examine  our  patient  very  carefully 
for  concealed  foci  of  infection,  which  if  found 
should  be  treated  and  the  patient  denied  marriage 
until  the  test  becomes  negative. 

The  gonorrhea  complement  fixation  test  is  en- 
tirely different  from  the  Wassermann  test  in  rela- 
tion to  treatment.  As  is  well  known,  the  Wasser- 
mann reaction  can  be  changed,  temporarily  at  least 
from  positive  to  negative  by  appropriate  treatment. 
Treatment  cannot  directly  affect  the  complem.ent 
fixation  test.  Authors  differ  as  to  the  effect  of 
gonococcus  vaccine  upon  the  test ;  some  state  that 
gonococcus  vaccine  will  not  produce  a  positive  test 
— this,  to  my  mind  is  wrong  and  cases  which  have 
been  treated  with  gonococcus  vaccine  should  not  be 


*Read    at    the    Joint    Meeting    of    the    Chicago    Medical 
and  Urological  Societies,  January  5,    1916. 


[Reprinted    from    THE   UROLOGIC    AND    CUTAXE- 
OUS    REVIEW.    April.    1916.] 


128 


examined  for  at  least  three  months  after  the  last 
dose  of  vaccine. 

The  autibodies  of  the  gonococcus  persist  in  the 
blood  stream  for  from  two  to  three  months  after  the 
death  of  the  last  gonococcus. 

The  errors  in  the  gonorrhea  complement  fixation 
test  arise  chiefly  on  the  negative  side.  We  obtain 
a  negative  reaction,  when  w'e  know  by  other  methods 
of  examination  that  gonococci  are  present  and  grow- 
ing in  the  body ;  we  practically  never  obtain  a  posi- 
tive test  in  any  disease  that  is  liable  to  be  mistaken 
for  gonorrhea  clinically. 

Conclusions. 

The  gonorrhea  complement  fixation  lest  is  of 
great  value  in  the  diagnosis  of  some  phases  of  gon- 
orrhea. 

The  test  errs  on  the  negative  side  more  than  on 
the  positive.  A  positive  result  means  gonorrhea; 
a  negative  result  means  nothing. 

Like  all  laboratory  tests,  the  test  should  be  given 
its  full  value,  but  it  should  not  be  overly  estimated, 
or  under  any  circumstances  be  considered  absolute. 


129 


COMPLICATIONS  OF  ACUTE  GONOR- 
RHEA IN  THE  MALE/"- 

By  Robt.   H.   Herbst,   M.   D.,  Chicago,   111. 

One  of  the  early  complications  of  a  gonococcus 
infection  in  the  male  urethra  is  phimosis.  This 
condition  is  usually  observed  in  an  individual  pos- 
sessing a  redundant  foreskin  and  in  whom  the  in- 
flammatory process  is  severe.  In  these  cases  there 
is  usually  a  co-existing  edema  and  swelling  of  all 
the  tissues  of  the  penis.  This  condition  should  be 
treated  by  frequent  prolonged  bathing  of  the  en- 
tire penis  in  hot  boric  acid  solution.  Should  this 
method  fail,  after  diligent  trial,  and  the  phimosis 
be  so  severe  as  to  prevent  local  treatment  to  the 
urethra,  circumcision  is  indicated. 

The  old  doctrine  that  circumcision  in  the  pres- 
ence of  infection  is  contraindicated  has  been  re- 
vised, and  today  we  recommend  circumcision  in 
cases  of  phimosis  when  the  condition  cannot  be 
relieved  by  simple  methods,   such  as  hot  bathing. 

The  old  Roser  dorsal  split,  although  a  simple 
means  of  relief,  is  usually  followed  by  poor  cos- 
metic results.  The  Hotentot  apron  which  remains, 
following  this  operation,  has  often  to  be  removed 
at  some  later  time. 

Lymphangitis  of  the  penis  with  a  subsequent 
adenitis  of  the  inguinal  glands  is  sometimes  seen  in 
highly  acute  inflammations;  usually  subsiding  with 
rest  and  hot  applications.  The  inflamed  inguinal 
glands  rarely  suppurate.  Should  these  glands  un- 
dergo suppuration,  incision  and  drainage  are  in- 
dicated. 

Paraphimosis  is  a  condition  where  we  find  the 
prepuce  caught  behind  the  glans  penis  and  like 
phimosis  is  usually  found  in  severe  cases  of  gonor- 
rhea. If  hot  bathing  prevents  reduction,  splitting 
of  the  contraction  ring  with  removal  of  the  fore- 
skin should  be  recommended. 

Infection  of  some  of  the  follicles  of  the  urethra 
participates  in  practically  every  gonococcus  infec- 
tion. In  cases  where  the  ducts  of  one  or  more  of 
these  follicles  become  obstructed  we  find  the  de- 
velopment of  an  abscess,  the  condition  known  as 
peri-urethral  abscess.  These  abscesses  gradually 
enlarge  and  when  not  interfered  with,  rupture  either 
externally  or  into  the  urethra.  Incision  or  exter- 
nal rupture  when  possible  should  be  avoided,  to 
obviate  the  possibility  of  a  resulting  fistula.  This 
can  frequently  be  prevented  by  incising  the  ab- 
scess in  the  urethra  with  the  aid  of  the  urethro- 
scope. 

Chordee,  a  complication  which  often  adds  greatly 
to  the  discomfort  of  the  patient,  is  caused  by  infil- 
tration  of   the   corpus    spongiosum.      Hot   or   cold 


*Read  before  the  Joint  Meeting  of  the  Chicago  Medical 
and  Urological  Societies,  January  5,    1916. 


[Reprinted  from   THE   UROLOGIC   AND   CUTANE- 
OUS   REVIEW,    April,    1916.] 

130 


bathing  of  the  penis  with  sedatives  to  prevent  erec- 
tion, as  a  rule,  reheves  the  condition. 

When  the  infection  spreads  to  the  floor  of  the 
bulbous  urethra  the  ducts  of  Cowper's  glands  soon 
become  infected,  with  a  later  extension  into  Cow- 
per's glcinds.  The  inflamed  glands  can  usually 
be  palpated  in  the  perineum  on  either  side  of  the 
median  line.  These  glands  may  merely  enlarge 
and  become  tender  or  they  may  go  on  to  suppura- 
tion. In  some  instances  it  is  necessary  to  excise 
them  or,  when  they  break  down,  to  incise  and  drain. 

In  at  least  60  per  cent,  of  all  gonococcus  infec- 
tions of  the  male  urethra,  we  find  the  process  ex- 
tending to  the  posterior  urethra  about  the  tenth 
day  or  shortly  after.  This  invasion  spreads  to  the 
edge  of  the  trigone  which  is  the  limit  of  the  col- 
umnar epithelium  and  commonly  the  limit  of  this 
infection;  because  as  is  well  known,  the  gonococcus 
usually  selects  the  columnar  type  and  for  this  reason 
the  bladder  mucosa,  being  of  the  squamous  type, 
is  rarely  involved.  The  condition,  commonly  termed 
gonorrheal  cystitis,  is  in  reality  merely  an  involve- 
ment of  the  trigone  producing  symptoms  of  frequent 
and  imperative  urination,  a  symptom-complex  often 
wrongly  attributed  to  inflammation  of  the  bladder 
mucosa.  It  is  my  belief  that  gonorrheal  cystitis 
rarely  occurs  except  in  cases  where  there  has  been 
a  pre-existing  trauma  of  the  bladder. 

The  prostatic  follicles  just  adjacent  to  the  pros- 
tatic urethra  are  usually  infected  when  the  gono- 
coccus invades  the  posterior  urethra.  Not  infre- 
quently this  process  extends  into  the  deeper  recesses 
of  the  gland  producing  what  is  termed  parenchyma- 
tous prostatitis.  This  condition  is  signalized  by  an 
increased  desire  to  urinate,  pain  in  the  perineum, 
chills  and  temperature.  These  symptoms  as  a  rule 
are  promptly  relieved  by  rest  in  bed,  applications 
of  heat  to  the  perineum,  and  the  introduction  of 
an  opium  suppository  into  the  rectum. 

With  the  appearance  of  abscess  of  the  prostate, 
symptoms  of  acute  prostatitis  are  intensified.  Upon 
the  introduction  of  the  examining  finger  into  the 
rectum  a  large  fluctuating  mass  is  felt.  Sometimes 
these  abscesses  rupture  spontaneously  into  the  ure- 
thra. When  the  suppuration  develops  toward  the 
rectal  side  of  the  gland,  incision  and  drainage  are 
indicated.  This  may  be  accomplished  by  making 
an  incision  through  the  gut  wall  or  by  making  a 
perineal  section,  dissecting  up  between  the  bladder 
and  rectum  until  the  abscess  cavity  is  reached. 

It  is  my  belief  that  the  gonococcus  rarely  infects 
the  posterior  urethra  without  first  invading  the 
ejaculatory  ducts  and  seminal  vesicles.  If  we 
bear  in  mind  the  anatomical  relation  of  these  parts, 
viz.,  that  the  ejaculatory  ducts  open  on  either  side 
of  the  utricle,  the  place  where  we  usually  find  a 
raging  inflammatory  process,  it  is  difficult  to  con- 
ceive how  these  organs  can  escape  mfection.  This 
contention  is  also  borne  out  clinically.  It  is  these 
very  ducts  and  vesicles  which   are  responsible  for 

131 


the  prolongation  of  many  urethral  discharges.  In 
the  past  we  have  given  all  our  attention  to  the 
treatment  of  the  urethra  and  have  sadly  neglected 
the  genital  tract  in  infections  of  this  character.  I 
am  satisfied  that  the  seminal  vesicles  frequently  feed 
the  urethra  with  gonococci.  Striking  examples  of 
this  condition  are  the  cases  which  give  us  a  his- 
tory of  discharge  from  the  urethra  following  prac- 
tically every  sexual  exposure  with  a  short  period 
of  incubation,  often  within  24  to  48  hours.  In 
other  words  the  urethra  is  infected  by  the  gonococcus 
laden  serum.  These  patients  not  infrequently  have 
chocolate  colored  seminal  discharges  due  to  ad- 
mixture of  blood  with  the  semen.  Cases  of  acute 
seminal  vesiculitis  rarely  heal  spontaneously,  in  the 
vast  majority  the  infection  persisting  until  the  vesi- 
cles are  either  directly  medicated  or  incised  and 
drained.  Vasostomy  followed  by  injection  of  col- 
largol  will  clean  up  many  of  these  cases.  Vesicu- 
lotomy smd  drainage  of  the  vesicles  should  be  re- 
served for  those  cases  in  which  there  is  a  stricture 
high  up  in  the  vas,  necessarily  preventing  any  solu- 
tion reaching  the  vesicles. 

Abscess  of  the  seminal  vesicles  develops  in  those 
cases  in  which  there  is  an  accumulation  of  pus 
within  the  vesicles  which  cannot  drain  into  the 
urethra  owing  to  occlusion  of  the  ejaculatory  duct 
due  to  inflammatory  swelling.  The  diagnosis  can 
as  a  rule  be  readily  made  by  rectal  examination, 
the  swollen  fluctuating  vesicle  being  easily  palpated. 
Given  an  individual  with  abscess  of  the  right  sem- 
inal vesicle,  the  necessity  for  differentiation  from 
appendicitis  may  arise.  Following  rectal  palpa- 
tion, the  condition  described  above  being  found, 
the  diagnosis  of  appendicitis  is  readily  ruled  out. 
These  abscesses  rarely  evacuate  into  the  urethra  and 
it  is  frequently  necessary  to  practice  incision  and 
drainage;  and  as  with  prostatic  abscesses  this  may 
be  accomplished  by  making  an  incision  either 
through  the  gut  or  by  a  dissection  through  the 
perineum. 

Acute  epididymitis,  a  rather  common  complica- 
tion of  gonorrhea  is  not  a  metastatic  infection,  but 
is  caused  by  gonococci  passing  from  the  seminal 
vesicles  to  the  epididymis  by  way  of  the  vas  def- 
erens. The  symptoms  are  those  of  an  acute  inflam- 
matory process,  viz.,  pain,  swelling,  tenderness  and 
rise  of  temperature.  Upon  examination  of  the 
scrotum  a  mass  is  felt  behind  the  testicle,  while  the 
body  of  the  testicle,  in  most  instances,  is  not  in- 
volved. There  is  not  infrequently  a  coincident 
effusion  into  the  sac  of  the  tunica  vaginalis.  The 
cord  is  greatly  thickened  and  is  tender  and  painful 
along  its  entire  course.  The  diagnosis  from  other 
infections  of  the  epididymis  does  not  as  a  rule 
offer  any  difficulty.  Although  the  signs  and  symp- 
toms of  acute  pus  infection  of  this  organ  are  the 
same  as  those  caused  by  the  gonococcus,  neverthe- 
less we  have  the  pre-existence  of  the  gonococcal  in- 
fection  of   the   urethra   to  help   us   in   making   the 

132 


diagnosis.  The  differentiation  from  tubercular  epi- 
didymitis offers  little  difficulty  if  we  bear  in  mind 
that  this  process  comes  on  in  a  slow,  insidious  man- 
ner, as  a  rule  without  pain  and  usually  developing 
in  the  upper  pole  of  the  organ  while  the  gonococcus 
infection  always  invades  the  lower  pole  first. 

The  discharge  from  the  urethra  generally  ceases 
temporarily  when  the  epididymis  swells.  This  is 
possibly  due  to  the  auto-vaccination  caused  by  the 
oncoming  of  the  acute  process  in  the  epididymis. 
The  discharge  recurs  when  the  swelling  of  the  epi- 
didymis begins  to  subside. 

Treatment. — It  is  well  known  that  some  pa- 
tients complain  of  pain  in  the  inguinal  canal  and 
have  swelling  of  the  cord  many  hours  before  in- 
volvement of  the  epididymis.  If  at  this  time  an  in- 
cision is  made  in  the  vas  deferens  midway  between 
the  upper  pole  of  the  epididymis  and  the  external 
ring  the  involvement  of  the  epididymis  may  be  pre- 
vented. In  mild  cases  of  acute  epididymitis,  eleva- 
tion of  the  scrotum  by  means  of  a  well-fitting  sus- 
pensory and  the  application  of  a  solution  of  guaiacol 
in  olive  oil,  1  to  4,  will  usually  give  the  desired 
relief.  If  this  fails  the  patient  should  be  put  to  bed 
with  the  scrotum  elevated  by  means  of  a  sling  and 
the  entire  scrotum  and  inguinal  region  covered  with 
a  hot  compress  moistened  with  saturated  solution 
of  magnesium  sulphate. 

In  very  severe  cases  with  enormous  swelling  of 
the  epididymis,  severe  pain,  high  temperature  and 
signs  of  fluctuation,  incision  and  drainage  are  in- 
dicated. 

The  incision  may  be  made  in  the  median  line 
posteriorly  and  the  epididymis  opened  without  en- 
tering the  sac  of  the  tunica  vaginalis.  In  cases 
where  we  are  dealing  with  a  hydrocele  and  have 
reason  to  believe  that  there  is  an  invasion  of  the 
tunica  vaginalis,  it  is  well  to  make  the  incision  on 
the  side  of  the  scrotum  so  as  to  open  the  sac  as 
well  as  the  epididymis.  In  every  instance  where 
we  are  dealing  with  an  infected  epididymis  we 
must  necessarily  have  a  pre-existing  infection  of 
the  vas  and  seminal  vesicles.  Therefore  at  the 
time  that  the  incision  of  the  epididymis  is  made  the 
vas  should  be  picked  up,  opened  and  the  vesicles 
injected  through  this  opening  with  collargol.  By 
so  doing  the  entire  seminal  duct  is  taken  care  of 
and  the  common  recurrent  infections  of  the  epididy- 
mis prevented.  In  my  work  the  use  of  vaccines 
and  serums  has  been  of  very  little  value  in  the 
treatment  of  gonococcal  infections,  although  I  have 
noted  some  beneficial  results  in  the  toxemias. 


133 


VULVO-VAGINITIS  IN  CHILDREN.* 

By  Isaac  A.  Abt,  M.  D.,  Chicago,  111. 

Gonorrhea  in  infants  and  children  may  occur 
not  only  in  the  female  child,  but  it  occasionally  oc- 
curs m  the  male.  It  is  not  uncommon  occasionally 
to  meet  with  a  case  of  gonorrheal  urethritis  in  a 
child  one  or  two  years  old  or  older.  Occasionally 
gonorrhea  occurs  in  the  mouths  of  very  young  in- 
fants. Rodinski,  many  years  ago,  described  gonor- 
rheal stomatitis  as  occurring  in  new-born  infants. 
One  need  hardly  refer  to  ophthalmia  neonatorum; 
but  one  may  mention,  in  passing,  gonorrhea  as  it 
occurs  in  the  lower  section  of  the  colon  or  rectum. 
It  is  not  at  all  unusual  to  find  that  infants  and 
children  are  gonorrhea  carriers,  the  infection  having 
taken  place  in  the  lower  segment  of  the  bowel. 

Gonorrheal  vulvo-vaginitis,  however,  may  occur 
in  infants  at  any  age,  but  more  particularly  in  chil- 
dren three  years  old  and  over. 

The  mode  of  infection  is  familiar  to  all  of  us. 
The  infection  may  be  conveyed  through  the  use 
of  thermometers,  utensils  of  various  kinds,  unclean 
linen,  contaminated  hands  of  nurses  or  attendants. 
The  latter,  in  some  instances,  are  supposed  to  be 
the  carriers  of  the  infection.  We  know,  for  instance, 
that  when  an  infant  or  a  child  enters  a  hospital 
ward  with  a  vulvo-vaginitis,  it  is  only  a  very  brief 
time  until  all  the  female  children  in  that  ward  are 
affected  with  gonorrheal  vulvo-vaginitis.  This  ma^' 
seem  an  extravagant  statement,  but  nevertheless  it 
is  true.  When  a  child  with  this  disease  has  en- 
tered a  ward,  it  is  almost  impossible,  even  in  the 
very  best  regulated  hospitals,  here  or  abroad,  to 
limit  gonorrheal  infection.  Statistics  gathered  from 
the  very  best  New  York  hospitals,  and  from  hos- 
pitals in  this  city,  show,  where  children  are  taken 
into  general  wards,  that  this  condition  does  prevail. 
Furthermore,  we  know  that  in  our  public  schools 
not  infrequently,  vulvo-vaginitis  is  spread,  either 
through  toilets  or  in  some  other  way  that  is  difficult 
to  divine.  Public  bathing  places  have  been  a 
means  of  disseminating  the  disease — for  example, 
take  the  celebrated  case  reported  from  the  City  of 
Posen.  In  a  public  bathing  establishment  in  that 
city,  after  the  older  girls,  on  certain  days,  had 
bathed,  the  little  girls  were  sent  to  bathe,  and  within 
two  or  three  days  following  bathing  there  was  a 
widespread  epidemic  of  vulvo-vaginitis. 

There  are  interesting  observations  about  the  dis- 
ease. Those  of  us  who  have  seen  a  great  many 
cases  of  vulvo-vaginitis,  are  impressed  with  the  fact 
that  very  frequently  the  disease  is  mild,  so  mild 
indeed  that  attention  is  not  directed  to  it  except  by 
the  discharge.      There  is  very  little  discomfort,  or 


*Read    at    the    Joint    Meeting    of    the    Chicago    Medical 
and    Urological    Societies,    January    5,     1916. 


[Reprinted    from    THE   UROLOGIC   AND   CUTANE- 
OUS   REVIEW,    April,    1916.] 


134 


very  little  external  irritation  in  the  milder  cases;  and 
this  raises  a  doubt  whether  this  vulvo-vaginitis  is  in 
all  cases  a  true  Neisserian  infection;  but  the  best 
of  authorities  state  that  we  should,  at  least,  assume 
that  the  disease  is  Neisserian  in  character  until  bet- 
ter proof  is  furnished  that  the  organism  is  not  sim- 
ply the  gonococcus. 

The  symptoms  in  the  severer  cases  consist  of  red- 
ness, swelling,  inability  to  walk,  difficulty  in  urina- 
tion, and  discharge. 

It  is  true  that  complications  are  relatively  un- 
common. One  is  surprised  at  the  fact  that  of  the 
large  number  of  cases  of  gonorrheal  vulvo-vaginitis, 
the  complications  are  few  and  far  between.  If  one 
goes  to  the  various  hospitals  and  studies  the  records, 
he  will  notice  very  few  complications.  In  a  large 
number  of  cases  recorded  in  the  Cook  County  Hos- 
pital, only  one  case  of  secondary  ophthalmia  is 
found. 

Agam,  gonorrheal  sepsis  in  infants  and  children 
is  relatively  rare.  This  is  amazing  because  we 
know  children  are  very  susceptible  to  sepsis  of  any 
kind.  The  infantile  organism  has  a  very  low  re- 
sistance against  general  infection.  It  is  but  p)oorly 
developed  in  antibodies.  Once  septic  infection  oc- 
curs in  an  infant,  a  severe  septic  process  may  be 
expected  or  is  likely  to  develop;  but  it  does  not 
seem  true  of  gonorrhea,  and  of  the  many  cases  I 
have  seen  I  remember  only  one  of  severe  gonorrheal 
arthritis,  with  endocarditis,  followed  by  death. 
Nevertheless,  gonorrheal  arthritis  does  occur  and 
manifests  itself  most  commonly  in  the  smaller  joints, 
the  joints  of  fingers  and  wrists;  it  is  relatively  un- 
common, although  not  impossible  of  occurrence, 
in  the  larger  joints. 

Vulvo-vaginitis  does  not  occur  only  at  the  in- 
troitus.  It  is  a  mistake  to  think  that  because  the 
discharge  is  mild  or  is  scant,  and  there  is  very  little 
evidence  of  external  irritation,  that  there  may  not 
be  gonorrhea  higher  up  in  the  vaginal  canal.  Rubin 
and  Leopold  have  shown,  by  introducing  electrical- 
ly lighted  instruments  into  the  vagina  in  infants  and 
children,  that  it  was  plainly  evident  the  wall  of  the 
vagina  higher  up,  and,  indeed,  the  cervix  and  cer- 
vical canal,  were  not  infrequently  covered  ^v^th  a 
muco-purulent  secretion,  indicating  that  gonorrheal 
vulvo-vaginitis  was  not  confined  to  the  lower  por- 
tion of  the  vagina,  but  that  it  may  be  present  higher 
up  on  the  cervix  or  cervical  canal  itself.  Notwith- 
standing this,  endometritis,  salpingitis,  and  peri- 
tonitis are  very  rare  complications,  so  that  one  may 
observe  many  cases  before  seeing  any  of  these  com- 
plications. 

Other  complications  are  inguinal  adenitis,  which 
is  extremely  rare,  and  enuresis  which  sometimes 
occurs. 

The  diagnosis  in  cases  of  vulvo-vaginitis  is  made 
by  the  abundant  secretion,  the  redness,  the  swelling, 
etc.      The   older   authors,   men   whose   descriptions 

135 


were  read  twenty  and  thirty  years  ago,  thought  this 
flux  was  due  to  some  dyscrasia  or  to  some  constitu- 
tional condition.  They  described  the  disease  oc- 
curring as  a  comphcation  of  scarlet  fever,  measles, 
typhoid  and  various  exhauslion  diseases. 

We  must  not  assume  that  all  cases  of  discharge 
from  the  vagina  of  infants  are  gonorrheal.  There 
may  be  notable  exceptions.  For  instance,  a  child 
that  has  aphthous  ulcers  m  the  vagmal  portion,  or 
that  has  infection  of  some  other  kmd,  may  be  easily 
shown  not  to  be  suffering  from  gonorrhea.  On  the 
other  hand,  pus,  from  the  vast  majority  of  cases, 
containing  the  intracellular  diplococci  is  assumed 
to  be  of  gonococcal  origin. 

Very  recently  a  method  of  diagnosis  has  been 
suggested  which  seems  to  me  to  be  very  valuable, 
and  esp>ecially  in  those  cases  where  doubt  exists. 
It  has  been  suggested  to  examine  the  vaginal  wash- 
ings. Kolmer  and  Pierce  have  adopted  the  sug- 
gestion of  Van  Gieson,  which  consists  of  injecting 
into  the  vagina,  with  a  soft  rubber  syringe,  or  with 
medicine  dropper,  one  to  four  or  five  thousand 
bichlorid  solution  in  normal  salt  solution,  and  thus 
allowing  the  vagina  to  be  ballooned  out  slightly. 
and  withdrawing  again  with  the  same  syringe  these 
washings,  and  in  this  way  obtaining  the  secretion 
from  all  portions  of  the  vagina,  und  obtaming  also 
the  epithelium  of  the  vagina  and  the  pus  cells. 
This  is  centrifuged  slowly  for  a  number  of  minutes, 
submitted  to  staining  reactions,  and  tested  for  gon- 
ococci. 

It  has  been  suggested,  too,  that  in  some  cases 
where  this  method  failed,  it  might  be  well  to  irri- 
gate with  mild  nitrate  of  silver  solution,  and  then 
examine  the  washings  by  centrifuging  as  I  have 
just  described.  This  method  of  diagnosis  seems 
of  considerable  value. 

Before  we  admit  children  into  a  general  ward  of 
a  hospital,  three  vaginal  examinations  should  be 
made  and  if  all  three  are  negative,  then  the  children 
may  be  admitted  into  the  ward. 

In  several  years  we  have  not  had  an  epidemic 
of  vulvo-vaginitis  at  the  Sarah  Morris  Children's 
Hospital.  Whether  this  is  simply  our  good  for- 
tune or  extraordinary  care,  I  would  not  like  to  say 
until  another  period  has  passed.  At  any  rate,  we 
can  congratulate  ourselves  that  no  epidemic  has  oc- 
curred. 

As  to  treatment,  my  own  experience  relates  par- 
ticularly to  the  methods  of  irrigation,  such  as  sitz 
baths.  I  have  tried  almost  everything  for  irrigation 
purposes,  and  I  have  thought  I  had  good  results 
in  some  cases,  while  in  others  I  have  not.  Some 
of  these  cases  will  get  well  in  a  few  weeks  and 
do  not  seem  to  have  relapses.  Others  again,  par- 
ticularly in  older  individuals,  will  improve  and  re- 
lapses will  occur.  The  disease  sometimes  is  very 
intractable  and  the  end  does  not  seem  to  be  in  sight. 

It  has  been  suggested  in  some  of  the  recent  lit- 
erature that  the  hymen  should  in  some  way  or  other 

136 


be  scarified  so  as  to  prevent  the  secretion  from  flow- 
ing freely  from  the  vaginal  portion,  or  it  should  be 
destroyed  under  cocain  anesthesia.  It  hag  been 
suggested,  furthermore,  to  mop  out  the  vagina  with 
a  strong  argyrol  solution,  and  then  follow  this  with 
irrigations  of  permanganate. 

In  a  series  of  cases  that  have  been  tested  with 
various  kinds  of  treatment  by  Hamilton  of  New 
York,  he  suggested  that  the  best  remedy  he  has 
found  is  Condy's  solution.  He  gets  better  results 
in  treatment  with  this  solution  than  with  cuiy  other 
method. 

So  far  as  the  vaccine  treatment  \n  children  is  con- 
cerned, there  are  others  who  are  more  expert  and 
know  more  about  it  than  I  do.  I  may  say,  how- 
ever, that  I  have  seen  positively  no  results  with  the 
vaccines  that  have  been  placed  in  my  hands. 


137 


PROSTITUTION  AND  GONORRHEA.* 

By  Lewis  Wine  Bremerman,  A.  M.,  M.  D.,  Chicago,  111. 

To  consider  a  subject  of  such  magnitude  as  pros- 
titution and  gonorrhea  in  the  short  space  of  time 
which  has  been  allotted  to  me,  would  be  utterly 
out  of  the  question,  so  I  can  only  bring  to  your 
attention  a  few  of  the  more  important  features  so 
as  to  succinctly  demonstrate  the  close  relations 
which  exist  between  prostitution  and  gonorrhea. 
This  entire  subject  depends  upon  what  is  meant 
by  the  term  prostitute. 

If  the  strictest  meaning  of  the  term  is  considered 
we  must  define  a  prostitute  as  a  Tvoman  given  to 
indiscriminate  lewdness  for  gain.  I  would  rather 
omit  the  words  "for  gain,"  and  emphasize  the  words 
"indiscriminate  lewdness,"  so  that  the  entire  field 
of  prostitution  is  covered  including:  The  clandes- 
tine prostitute,  the  kept  woman,  and  the  married 
woman.  Any  one  from  these  classes  might  prosti- 
tute herself  without  monetary  gain.  Even  with 
the  definition  as  above  I  am  still  rather  inclined  to 
find  it  incomplete  as  it  leaves  entirely  out  of  the 
question  that  great  army  of  infection  bearers  that 
exists  in  the  "so-called  cured"  male  prostitute. 
We  should  then  define  a  prostitute  as  a  man  or 
Tvoman  given  to  indiscriminate  lewdness.  The  male 
is  not  such  an  pernicious  infection  spreader  as  the 
female.  Even  at  the  outside  one  male  would  only 
infect  a  relatively  small  number  of  females,  whereas 
the  female  may  infect  large  numbers.  I  have  known 
cases  where  females  suffering  with  a  virulent  gono- 
coccal infection  would  have  intercourse  with  twenty 
men  in  one  night,  thus  infecting  large  numbers  of 
men.  The  female  prostitute  is  the  more  dangerous 
to  the  greatest  number  and  therefore  some  measures 
should  be  taken  to  prevent  her,  if  you  please,  from 
wilfully  spreading  an  infection  which  may  be  more 
widespread  in  its  consequence  than  any  other  known 
disease.  A  few  years  ago  I  was  asked  to  read 
a  paper  upon  a  similar  subject  but  was  unable  to 
finish  it  on  account  of  illness.  Some  of  the  statis- 
tics gathered  at  that  time  I  will  quote  to  show  ac- 
curately from  direct  examination  and  careful  ques- 
tioning just  how  prevalent  gonorrhea  is  among  the 
commonly  termed  professional  prostitute  whose  trade 
is  not  controlled  by  segregation  or  sanitary  regula- 
tion. 

These  statistics  were  collected  in  New  York 
shortly  following  the  closing  of  the  "red-light" 
district  of  that  city.  These  women  were  consid- 
ered to  be  the  better  class  of  prostitutes.  I  had 
planned  to  examine  one  thousand  women,  but  only 
had  the  opportunity  of  examining  746.  Of  these 
746,    1  00  per  cent,  had  been  prostitutes  for  over 

*Read  at  the  joint  meeting  of  the  Chicago  Medical  and 
Urological    Societies,    January    5,    1916. 


[Reprinted    from    THE   UROLOGIC   AND   CUTANE- 
OU.S    REVIEW,    April,    1916.] 

138 


three  years.  These  women  ranged  in  age  from  1  8 
to  36,  the  majority  being  between  2 1  and  30. 
702  of  the  746,  or  93  per  cent.,  had  gonorrhea 
or  had  been  infected  previously  and  only  44,  or 
7  per  cent,  negative  cases  denied  all  infection  and 
had  no  evidence  of  such  at  the  examination. 

At  the  time  of  the  examination  219  or  30  per 
cent,  had  microscopic  Gram  negative  diplococci 
which  were  diagnosed  gonococci  without  other  clin- 
ical manifestations.  These  women  were  all  plying 
their  business  and  probably  infecting  a  good  pro- 
portion of  the  males  with  whom  they  were  cohabit- 
ing. Twenty-nine  or  1  1  per  cent,  had  evidence 
of  other  venereal  diseases  and  were  likewise  spread- 
ing infection.  Sixteen  or  2  per  cent,  had  marked 
clinical  symptoms  and  were  not  cohabiting  at  all 
according  to  their  statement  and  would  not  do  so 
until  the  discharge  ceased.  Not  a  single  one  told 
me  that  she  would  refrain  from  intercourse  until 
she  was  proven  to  be  free  from  disease  by  all  known 
laboratory  tests.  Forty-five  or  6  per  cent,  had  been 
operated  upon  for,  as  they  termed  it,  peritonitis 
^vhich  no  doubt  was  associated  with  a  pyosalpinx 
of  gonorrheal  origin. 

You  will  notice  that  my  figures  show  very  few 
active  cases.  I  did  not  get  the  opportunity  of 
seeing  this  type. 

In  my  opinion  sooner  or  later  1  00  per  cent,  of 
the  women  who  enter  prostitution  or  give  themselves 
to  indiscriminate  lewdness  will  contract  some  of 
venereal  disease.  These  infections  are  naturally 
contracted  from  the  male.  I  have  no  doubt  that 
the  male  spreads  the  disease  not  wilfully  but  through 
ignorance,  believing  himself  to  be  cured  when  really 
there  are  still  lurking  somewhere  in  the  genital  tract 
active  infectious  organisms. 

Men  will  not  indulge,  as  a  rule,  in  intercourse 
when  they  are  suffering  with  the  acute  type  of  gon- 
orrhea, knowing  very  well  that  such  excitement 
will  usually  exaggerate  and  accentuate  their  symp- 
toms which  may  terminate  in  grave  complication. 
I  believe  thoroughly  if  the  layman,  yes,  and  the 
doctor  as  well,  were  instructed  in  the  dreadful 
consequences  of  gonorrhea,  that  the  condition  is  not 
cured  when  the  discharge  is  stopped,  and  that  many 
accurate  examinations  must  be  made  prior  to  giving 
an  opinion  regarding  the  infectious  nature  of  the 
individual,  that  the  male  would  be  decidedly  more 
careful  in  exposing  himself. 

If  the  layman  were  cognizant  of  these  things  he 
himself  would  insist  upon  such  examination  and 
would  necessarily  demand  that  his  physician  be 
qualified  to  make  it. 

A  few  years  ago  a  patient  coming  to  us  prior 
to  his  marriage  for  an  examination  to  determine 
whether  or  not  he  had  any  of  his  old  gonorrhea 
remaining  was  a  rarity.  A  year  or  two  ago  there 
was  produced  a  play  called  "Damaged  Goods" 
which  portrayed  graphically  the  effects  of  venereal 
disease.      Since  that  time  hardly  a  week  goes  by 

139 


that  we  do  not  have  a  case  or  two  come  to  us  for 
such  an  examination. 

There  should  be  more  such  plays  produced  for 
layman  and  a  wider  propaganda  of  education  along 
these  lines  which  would  be  without  question  fol- 
lowed by  great  good.  The  social  evil  cannot  in 
my  opinion  be  overcome  so  long  as  there  exists  the 
differences  in  the  sexes  and  the  natural  sexual  in- 
stinct. 

Prostitution  should  be  controlled  by  segregation 
and  by  sanitary  regulation  which  without  question 
could  reduce  markedly  the  number  of  venereal  in- 
fections. 

My  own  statistics  show  that  the  majority  of  cases 
of  gonorrhea  have  not  originated  from  the  profes- 
sional prostitute  who  frequents  a  well-regulated 
house,  and  that  gonorrhea  does  develop  more  fre- 
quently in  the  male  who  cohabits  with  the  shop 
girl,  the  street  walker,  or  the  so-called  "private 
snap." 

The  proprietors  of  well-regulated  houses  recog- 
nize the  importance  of  keeping  the  girls  who  be- 
come infected  from  cohabiting  until  well. 

If  these  houses  could  be  under  a  well-regulated 
sanitary  inspection  the  chances  of  contracting  ven- 
ereal disease  would  be  reduced  still  lower. 

The  female  prostitute,  even  though  she  is  a  so- 
cial outcast  should  be  protected  as  far  as  possible. 
She  should  be  instructed  at  least  to  make  such  an 
examination  of  the  male  as  would  inform  her  whether 
or  not  there  is  urethral  discharge.  She  should  be 
instructed  in  the  proper  methods  of  taking  care  of 
herself,  and  by  these  precautions  reduce  to  minimum 
her  chances  for  infection.  She  should  be  instructed 
in  the  early  manifestation  of  the  disease  so  that  she 
could  immediately  place  herself  under  medical  at- 
tention. 

A  severe  penalty  should  follow  if  women  who  are 
known  prostitutes,  practice  their  trade  when  they  are 
infected. 

To  summarize:  I  feel  that  segregation  with 
strict  sanitary  regulation  together  with  the  education 
of  the  lay  people  regarding  sex  matters  and  ven- 
ereal disease  would  reduce  to  a  marked  degree  the 
present  terrific  and  wide-spread  infections  of  this 
character  which  are  more  damaging  to  the  human 
race  than  any  other  disease,  even  including  tuber- 
culosis and  cancer. 


140 


GONORRHEA  AND  MARRIAGE.^ 

By  Irvin  S.  Koll-.  M.  D.,  F.  A.  C.  S.,  Chicago,  111., 
Professor  Cenito- Urinary   Surgery,  Post-Craduate  Medical 

School;     Associate     Ceni  to- Urinary     Sur- 
gery,   Michael    Reese    Hospital. 

The  question  of  the  marriage  of  gonorrheics 
should  occupy  the  most  serious  consideration  of  the 
entire  medical  profession.  It  is  amazing  to  know, 
however,  how  little  knowledge  the  average  man  in 
general  medicine  has  regarding  the  length  of  time 
a  patient  who  has  had  a  gonococcal  infection  is  a 
source  of  danger  to  the  female.  Yet  I  am  sure 
that  every  man  in  this  gathering  knows  of  more 
than  one  case  where  the  honeymoon  was  abruptly 
ended  by  the  bride  falling  a  victim  to  the  ravages 
of  the  gonococcus,  with  sterility  and  invalidism  re- 
sulting. 

The  discussion,  then,  of  this  point  in  our  sym- 
posium resolves  itself  into  the  consideration  of  the 
persistence  of  the  gonococcus  in  the  male  genito- 
urinary organs.  Under  this  caption,  Edward  L. 
Keyes,  Jr.,  four  years  ago  stated  that  he  had  "never 
known  the  gonococcus  to  persist  in  the  male  urethra 
for  more  than  three  years,  while  in  at  least  ninety 
per  cent,  of  cases  it  disappears  with  or  without  treat- 
ment within  a  year."  This  statement  from  one  of 
the  keenest  of  observers,  of  the  widest  experience, 
should  be  taken  for  just  exactly  what  is  means. 
But  what  about  the  remaining  ten  per  cent,  in 
which  the  gonococcus  persists  for  more  than  one 
year? 

I  believe  that  most  of  my  urological  colleagues 
will  concur  with  me  in  general  with  the  rules  laid 
down  to  candidates  for  matrimony  who  have  had 
gonorrhea. 

If  the  infection  was  limited  to  the  anterior  ure- 
thra, which  is  determined  from  the  clinical  history, 
and  every  evidence  of  the  disease  has  disappeared, 
one  year  must  have  elapsed  from  the  time  of  the 
last  evidence  of  the  infection  before  consent  is  given 
for  marriage.  The  patient  is  then  put  through  a 
series  of  tests,  to  be  described  presently. 

If  the  pathology  extended  into  the  posterior 
urethra,  thereby  involving  the  prostate  and  vesicles, 
more  or  less,  then  two  years  must  elapse  following 
the  final  clinical  disappearance  of  the  disease,  and 
the  laboratory  tests  remain  negative. 

Instrumentation,  alcohol  test,  and  strenuous  phy- 
sical exertion  are  tried.  The  patient  is  furnished 
with  slides  upon  which  any  morning  discharge  is 
placed,  which  is  carefully  examined.  The  first 
urine  is  collected,  centrifuged  cuid  examined  bac- 
teriologically.      Cultures    are   made   the    following 


*Read    at    the    Joint    Meeting    of    the    Chicago    Medical 
and  Urological   Societies,  January   5,    1916. 


[Reprinted    from    THE    UROLOGIC   AND    CUTANE- 
OUS   REVIEW.    April.    1916.] 

141 


day  from  the  discharge,  urine  and  prostatic  secre- 
tion obtained  by  massage.  In  some  instances  cul- 
tures are  taken  from  the  semen  ejaculated  into  a 
sterile  condom.  The  complement  fixation  test  is 
by  no  means  of  the  last  importance,  but  I  feel  that 
up  to  the  present  our  technique  is  not  sufficiently  de- 
veloped to  cause  us  to  make  any  dogmatic  deduc- 
tions.    I  shall  recur  to  this  point  immediately. 

This  is  not  the  time  to  discuss  the  technique  of 
the  various  laboratory  tests,  which  are  intricate  and 
delicate,  and  give  abundant  opportunity  for  error  m 
inexperienced  hands,  particularly  in  the  interpreta- 
tion of  the  bacterial  culture.  This  is  especially  true 
since  our  attention  has  been  called  by  Warden  to  the 
fact  that  many  bacteria  are  w^rongly  diagnosed  as 
the  gonococci. 

To  revert  now  to  the  serum  reaction,  which  can 
be  considered  but  briefly  in  this  connection : 

I  quote  from  Dr.  Warden,  who  was  kind  enough 
to  answer  three  questions  I  put  to  him : 

1 .  "I  believe  it  is  possible  to  obtain  a  positive 
fixation  test  in  the  absence,  so  far  as  the  evidence  of 
smears  and  cultures  goes,  of  the  gonococci  in  the 
genito-urinary  tract." 

2.  "I  believe  that  in  some  cases,  even  when  all 
clinical  signs  have  been  absent  for  years,  a  fixation 
may  be  obtained.  A  few  instances  of  fixation  as 
long  cis  twenty  years  have  been  noted  by  other 
observers  as  well  as  ourselves." 

3.  "I  should  certainly  withhold  consent  to 
marriage  in  the  presence  of  a  positive  test,  whether 
two  years  without  symptoms  had  passed  or  no." 

No  one  more  than  I  recognizes  the  admirable 
work  that  Dr.  Warden  has  done  in  this  connection, 
but  as  he  admits  that  it  is  possible  to  obtain  a  posi- 
tive fixation  in  an  individual  clinically  cured  for 
twenty  years,  I  am  quite  confident  he  would  not 
deny  that  man  on  this  test  alone  the  privilege  of 
marrying.  Therefore,  so  far  the  serum  test,  in 
the  opinion  of  the  writer,  is  of  no  definite  value  in 
designating  a  cured  gonorrhea,  but  every  confidence 
is  entertained  for  its  future  reliability. 

In  a  final  word,  let  me  exhort,  if  I  may : 

1 .  The  education  of  fathers  interviewing  their 
prospective  sons-in-law  to  inquire  into  the  condi- 
tion of  their  genito-urinary  tract,  as  well  as  into 
the  condition  of  their  bank  accounts. 

2.  A  more  serious  inquiry  on  the  part  of  gen- 
eral practitioners  into  the  gonorrheal  history  of  their 
patients,  by  whom  they  are  many  times  more  fre- 
quently consulted  than  falls  to  the  lot  of  the  genito- 
urinary specialist. 

25   East  Washington  Street. 


142 


TRANSACTIONS 

Joint  Meeting  of  the  Chicago  Medical 

AND        UrOLOGICAL        SOCIETIES,        HeLD 

January  5,  1916,  With  Dr.  Her- 
man   L.    Kretschmer    in 
the  Chair. 

Papers  were  read  as  follows: 

1 .  Bio-Chemistry  and  Bacteriology  of  the  Gon- 
ococcus,  by  Dr.  C.  C.  Warden,  Ann  Arbor, 
Michigan. 

2.  Complement  Fixation  Test,  by  Dr.  Victor 
D.   Lespinasse. 

3.  Complications  of  Acute  Gonorrhea,  by  Dr. 
Robert  H.  Herbst. 

4.  Vulvo-Vaginitis  in  Children,  by  Dr.  Isaac 
A.  Abt. 

5.  Gonorrhea  and  Prostitution,  by  Dr.  L.  W. 
Bremerman. 

6.  Gonorrhea  and  Marriage,  by  Dr.  Irvin  S. 
Koll. 

(All  of  the  above  named  papers  appear  in  this 
[April]   issue  of  the  Urologic  AND  CUTANEOUS 

Review.) 

Discussion  of  the  Symposium  on 
Gonorrhea. 

Dr.  Ralph  W.  Webster:  There  are  certain 
points  that  have  been  raised  especially  by  Dr. 
Warden  and  by  Dr.  Koll  which  I  would  like  to 
discuss  briefly,  and  particularly  some  of  the  earlier 
work  of  Dr.  Warden. 

As  I  recall  the  earlier  papers  of  Dr.  Warden, 
definite  statements  were  made  at  the  time  which 
rather  shocked  me,  but  as  I  have  studied  the  ques- 
tion later  I  have  come  to  agree  almost  entirely  with 
him.  The  first  of  these  was  the  statement  in  the 
original  paper  of  Dr.  Warden  in  italics,  so  that 
none  might  miss  it,  that  "Gram  negative  intracellular 
biscuit-shaped  diplococci  in  smears  were  almost  in- 
variably shown  on  culture  to  be  staphylococci."  At 
that  time  this  statement  seemed  rather  startling,  when 
we  consider  that  every  phase  or  every  known  ear- 
mark of  the  gonococcus  was  mentioned  and  the  con- 
clusion drawn  when  a  culture  was  made  from 
the  pus  containing  the  Gram  negative  intracellular 
biscuit-shaped  diplococci,  they  were  not  gonococci. 

Since  that  time  it  has  been  my  good  fortune 
frequently  to  examine  smears  and  to  compare  these 
smears  with  cultures  from  cases  of  supposed  gonor- 
rhea. I  must  say  that  work  done  along  these  lines, 
which  by  no  means  makes  any  pretense  to  being 
extensive,  confirms  Dr.  Warden's  ideas  fully,  that 
is,  in  a  smear,  whether  it  be  from  a  case  of  clinical 
gonorrhea,  acute  gonorrhea,  whether  it  be  from 
chronic  supp>osed  gonorrhea,  or  from  a  condition  of 


[Reprinted   from   THE   UROLOGIC   AND    CUTANE- 
OUS   REVIEW,    April.    1 91 6.1 

143 


genito-urinary  irritation  with  pus  formation,  we 
find  this  Gram  negative  intracellular  biscuit-shaped 
diplococcus,  but  in  the  majority  of  cases  the  or- 
ganisms grow  very  well  on  plain  agar  and  upon 
other  media  upon  which  the  true  gonococcus  does 
not  grow.  We  must  either  accept  the  view  that 
the  gonococcus  will  not  grow  on  plain  agar  or  on 
other  culture  media,  or  we  must  give  up  our  idea 
that  the  gonococcus  is  the  only  organism  which 
shows  the  characteristics  I  have  mentioned. 

I  believe  the  time  is  at  hand  when  we  must 
admit  that  a  very  large  percentage  of  cases  of 
genito-urinary  infection  are  due  to  other  organisms 
than  the  gonococcus,  and  personally  my  belief  is 
that  the  organism  which  is  the  invader  in  a  large 
percentage  of  the  cases  is  the  micrococcus  catarrhalis 
which,  up  to  the  present  time,  has  not  found  its 
way  into  the  text-books  to  a  great  extent,  but  never- 
theless, is  one  which  I  believe,  personally,  from 
work  done  in  my  laboratory,  to  be  the  organism 
which  we  must  consider  to  a  very  large  extent.  I 
do  not  mean  by  this  that  we  do  not  have  typical 
gonorrhea,  but  I  do  mean  that  many  people  have 
been  damned  as  gonorrheics  when  they  were  not 
such.  This  leads  to  the  point  mentioned  by  Dr. 
KoU  as  to  whether  all  these  cases  should  be  amen- 
able to  the  complement  fixation  test.  If  we  as- 
sume that  we  must  find  in  the  urine  or  in  the  prostatic 
discharge,  or  in  the  urethral  discharge,  whether  it 
be  anterior  or  posterior,  the  specific  organisms  and 
consider  them  always  gonococcic,  it  is  rather  hard 
to  understand  why  we  do  not  always  get  the  com- 
plement fixation  test.  If  we  assume  they  are  not 
gonococci,  but  some  other  organism,  we  can  under- 
stand why  the  variation  of  the  complement  fixation 
test  is  so  marked,  and  why  the  difference  of  opinion 
is  quite  distinct  with  clinicians. 

There  are  several  other  points  I  would  like  to 
take  up,  but  I  do  not  feel  I  have  the  time  to  do  so. 

Dr.  Albert  E.  Mowry:  It  seems  to  me, 
we  should  strive  to  come  to  a  practical  solution 
of  this  question  and  circulate  pamphlets  or  devise 
some  means  to  prevent  venereal  diseases  and  give 
advice  to  men  who  are  going  to  marry  who  have 
had  gonorrhea,  so  that  they  may  not  infect  their 
wives. 

We  ought  to  publish  little  pamphlets  in  reference 
to  venereal  prophylaxis,  and  this  can  be  done  if 
we  study  the  matter  carefully  and  thoughtfully. 
We  can  get  venereal  prophylaxis  so  that  there  will 
be  very  little  venereal  disease  disseminated. 

We  must  consider  this  matter  from  a  practical 
standpoint,  because  we  are  not  going  to  reform 
the  world  for  many  years.  When  I  think  of  the 
statement  of  Noeggerath,  I  am  inclined  to  agree 
with  him  that  "once  a  gonorrheic,  always  a  gonor- 
rheic,"  is  not  a  great  ways  from  the  truth,  in  chronic 
cases. 

In  the  army,  when  I  was  in  the  service  as  assist- 
ant surgeon  in  the  Spanish-American  War,  many 

144 


men  who  had  passed  examination  for  army  service 
with  close  scrutiny  for  latent  gonorrhea  and  pro- 
nounced free  of  such  would  suffer  with  types  of 
diarrhea  and  dysentery  which  irritated  the  deep 
urethra,  so  that  it  would  set  up  a  profuse  dis- 
charge in  which  we  could  find  plenty  of  gonococci. 

The  more  I  see  of  gonorrhea  the  more  I  realize 
that  it  is  in  the  adnexa  of  the  urethra,  and  we  can 
almost  figure  we  are  going  to  have  it  for  a  great 
mcuiy  years. 

We  should  not  forget  that  we  are  still  trying 
to  find  a  method  to  cure  chronic  urethritis  and  not 
put  all  efforts  into  experiments  on  chronic  gonorrhea 
of  the  genital  tract. 

Dr.  J,  S.  ElSENSTAEDT:  The  remarks  of  Dr. 
Abt  in  regard  to  the  indefiniteness  of  cure  of  vulvo- 
vaginitis in  children,  and  that  some  of  them  get 
well  in  a  short  time  and  others  persist  for  months, 
remind  me  of  the  recent  reports  from  Germany  in 
the  use  of  ethyl  cuprein  hydrochlorid,  which  was 
used  originally  against  pneumococcus  infection,  but 
has  been  used  over  there  in  cases  of  vulvo-vaginitis 
in  children  \vith  astonishingly  good  results  by  several 
reporters.  I  have  made  use  of  this  in  two  cases 
in  Chicago  with  distinct  improvement,  but  the  time 
has  been  too  short  to  state  definitely  the  ultimate 
results. 

Optochin  has  been  used  with  success  in  cases  of 
gonorrhea  in  all  stages,  particularly  in  those  cases 
which  have  proved  refractory  to  the  various  silver 
salts.  The  drug  has  a  peculiar  dissolving  capacity 
upon  the  capsule  of  the  organism. 

In  regard  to  the  statements  concerning  prophy- 
laxis in  the  various  armies,  it  is  a  fact  that  in  our 
Navy  the  number  of  venereal  cases  has  diminished 
very  f>erceptibly.  In  one  report  of  cases  of  men 
admitted  to  hospitals  on  account  of  venereal  dis- 
ease, it  is  said  the  number  has  decreased  over  30 
per  cent.  I  am  informed — I  have  not  definite  au- 
thority, and  do  not  know  how  accurate  the  informa- 
tion is — that  the  secretaries  of  both  the  Army  and 
Navy  of  the  United  States  have  decided  to  do  away 
with  prophylaxis,  particularly  in  the  Navy.  Pro- 
phylaxis was  considered  extremely  effective  and 
efficient,  and  to  do  away  with  it  strikes  me  as 
being  very  peculiar.  This  matter  should  be  called 
to  the  attention  of  men  who  are  interested  in  urology 
and  venereal  disease.  Where  we  have  in  our  hands 
a  preparation,  like  33  per  cent,  calomel,  with  the 
addition  of  thymol  in  lanolin,  and  2  per  cent,  albar- 
gin,  or  a  strong  solution  of  protargol,  which  is  a 
preventive  against  gonorrhea,  I  think  such  methods 
should  be  greatly  encouraged. 

Dr.  Herman  L.  Kretschmer:  I  should 
like  to  discuss  briefly  the  paper  of  Dr.  Herbst,  who 
brought  up  the  treatment  of  some  of  the  complica- 
tions of   gonorrhea. 

With  reference  to  the  surgical  treatment  of  gon- 
orrheal epididymitis,  one  frequently  sees  in  the  litera- 
ture statements  made  relative  to  the  value  of  surgical 

145 


treatment.  Surgical  treatment  is  of  distinct  value 
in  such  cases  as  it  reduces  pain,  the  temperature 
goes  down  within  twenty-four  hours,  and  the  leuco- 
cytes diminish  in  number.  I  do  not  think,  how- 
ever, surgical  treatment  is  of  any  value  in  the  pre- 
vention of  recurrences.  I  have  seen  three  or  four 
patients  operated  upon  in  this  way,  a  typical  epidi- 
dymotomy  being  done,  and  yet  these  patients  have 
had   recurrences. 

It  is  interesting  to  study  the  pathology  in  con- 
nection with  the  cases  operated  upon.  In  some  cases 
one  finds  agglutination  of  the  visceral  and  parietal 
layers  of  the  tunica  vaginalis.  In  other  cases  we 
find  a  large  quantity  of  hydrocele  fluid.  Some- 
times the  sac  of  the  tunica  vaginalis  is  empty  or 
contains  just  a  few  drams,  while  the  epididymis 
and  body  of  the  testicle  are  covered  with  exudate. 

I  do  not  see  the  logic  in  Dr.  Mowry's  argument 
with  reference  to  urination  being  a  prophylactic 
when  we  know  so  many  times  the  gonococci  are 
harbored  in  the  prostate  and  seminal  vesicles,  nor 
can  I  agree  with  the  statement  that  "once  a  gonor- 
rheic  always  a  gonorrheic." 

I  should  like  to  ask  Dr.  Abt  to  tell  us  the 
reasons  why  little  children  who  are  so  susceptible 
to  infections  of  various  kinds  do  not  have  more 
infections  from  vulvo-vaginitis,  particularly  with 
reference  to  ophthalmia.  These  children  cannot 
be  instructed.  I  do  not  know  why  they  do  not 
have   ophthalmia    more    than    they    do. 

Dr.  C.  C.  Warden  (closing  on  his  part) : 
A  word  in  regard  to  complement  fixation.  Com- 
plement fixation  in  gonorrheal  infections  is  apparent- 
ly not  fully  and  clearly  understood.  There  are 
some  peculiar  things  about  it  and  some  very  em- 
barrassing things,  but  I  think  eventually  they  will 
be  worked  out.  As  Dr.  Lespinasse  says,  the  re- 
action is  not  positive  until  from  four  to  six  weeks 
of  the  disease.  If  the  reaction  remained  positive 
throughout  the  inflammation  it  would  be  of  great 
value,  but  it  is  not  so.  If  a  case  is  observed  period- 
ically every  few  days  throughout  an  attack  of  gon- 
orrhea, or  if  several  cases  are  observed  periodically, 
it  will  be  found  at  some  time  during  the  process 
of  inflammation  the  reaction  will  be  fX)sitive.  In- 
side of  a  few  days  it  will  be  negative,  then  a 
few  days  again  it  will  be  positive,  and  then  later 
again  will  be  found  another  negative,  so  that  the 
reaction  seems  to  proceed  in  waves.  One  negative 
reaction  in  complement  fixation  work  is  of  no  value ; 
repeated  negative  complement  fixations,  particularly 
in  the  presence  of  one  of  the  clinical  signs  of  gonor- 
rhea, are  of  great  value.  I  believe  a  positive  com- 
plement fixation  test  is  invariably  of  value.  There 
are  peculiar  cases  which  everyone  has  observed, 
where  a  positive  reaction  is  obtained  for  thirty  years 
after  gonorrhea.  These  cases  I  do  not  believe 
have  been  worked  out,  although  there  may  be  cases 
where  the  gonococcus  may  be  present  in  the  body 
without   any   signs   of   the   disease   existing.      This 

146 


applies  particularly  to  children  and  to  women,  and 
the  more  I  study  the  subject,  the  more  I  am  con- 
vinced that  in  the  female,  and  occasionally  in  the 
male,  we  find  a  condition  where  the  individual  is  a 
carrier  of  the  gonococcus,  where  the  germs  can  sub- 
sist upon  the  mucous  membrane  without  producing 
inflammation  in  that  particular  individual.  I  have 
seen  several  times  in  children  and  adult  females 
the  presence  of  the  gonococcus  by  culture  where 
there  were  no  clinical  manifestations  at  all.  These 
cases  have  given  rise  to  infections  in  the  male,  so 
that  I  believe  this  organism  is  no  exception,  that 
it  follows  the  rule  of  other  organisms,  and  that  fre- 
quently we  have  carriers  of  the  gonococcus  just  as 
we  have  carriers  of  the  diphtheria  bacillus  and  of 
other  similar  germs. 

With  reference  to  the  question  of  diagnosis,  I 
believe  it  is  an  error,  particularly  in  women  and 
in  children,  to  expect  to  make  a  diagnosis  from  a 
smear  alone,  and  this  is  particularly  applicable 
in  those  cases  where  the  picture  is  not  clear,  as 
in  chronic  cases.  There  are  many  organisms  which 
may  be  confused  with  the  gonococcus  in  smears, 
and  unquestionably  some  of  the  children  and  a  great 
many  of  the  women  have  the  stigma  put  upon  them 
unjustly.  There  are  many  cachetic,  anemic,  stru- 
mous children  in  hospitals  that  have  plenty  of  se- 
cretion from  the  vagina,  and  with  repeated  nega- 
tive complement  fixation,  there  is  found  to  be  an 
utter  absence  of  the  gonococcus. 

The  staphylococcus,  as  it  appears  in  smears  from 
the  urethra,  is  extremely  deceptive  and  cannot  by 
any  means  be  distinguished  from  the  gonococcus. 
The  gonococcus  is  not  a  diplococcus  to  begin  with. 
It  is  a  micrococcus,  and  hke  a  great  many  of  the 
cocci  family  undergoes  division  by  splitting  in  the 
biscuit  form. 

In  a  publication  some  two  or  three  years  ago, 
in  which  I  laid  considerable  emphasis  upon  the 
staphylococcus,  I  was  severely  taken  to  task  by 
Eastern  brothers,  but  there  was  no  evidence  brought 
forward  to  negative  the  assertion  which  I  then  made, 
that  the  staphylococcus,  undergoing  division  and 
having  the  biscuit  form  m  smears  from  any  source, 
was  indistinguishable  from  the  gonococcus.  What 
role  the  staphylococcus  assumes  in  the  inflammations 
in  the  later  stages  of  gonorrhea  I  do  not  know. 
A  smear  from  a  case  of  acute  gonorrhea,  where 
the  cells  are  full  of  cocci  or  characterislic  orsanisms, 
in  the  utter  absence  of  any  other  germ  in  the  field. 
I  accept  without  other  clinical  sign  as  being  strongly 
indicative  of  acute  gonorrhea,  but  I  do  not  allow 
myself  to  be  satisfied  with  that  alone. 

Sometimes  we  receive  a  smear  from  the  case  of 
a  woman  with  the  question.  Has  this  woman  gon- 
orrhea or  not?  In  that  smear  we  will  find  a  great 
number  of  bacteria,  great  numbers  of  all  kinds  of 
bacteria,  all  members  of  the  cocci  family,  with 
bacilli  and  streptococci,  and  every  manner  of  or- 
ganism,   and   just   because   a    few   leucocytes   may 

147 


contain  three  or  four  Gram  negative  intracellular 
organisms,  to  say  the  woman  has  gonorrhea  is  a 
mistake.  I  say  to  the  doctor,  I  am  unable  to 
say  definitely.  If  the  laboratory  man  cannot  tell, 
how  am  I  to  know?,  the  doctor  may  ask.  By 
proceeding  further  using  repeated  complement  fix- 
ations and  cultures,  and  if  a  positive  complement 
fixation  or  positive  culture  is  shown  the  diagnosis  is 
accepted. 

With  reference  to  segregation,  I  would  favor 
ideal  segregation  which  will  keep  the  professed 
prostitute  within  certain  bounds;  but  as  to  the  ex- 
amination of  professional  prostitutes,  as  these  ex- 
aminations are  conducted  in  a  great  many  cities, 
they  are  imperfect.  I  have  one  particularly  in  mind 
where  the  inmates  come  up  for  examination  under 
police  guidance.  If  those  patients  are  shown  to 
be  positive  they  are  thrown  out  of  the  house  and 
upon  the  town.  They  apply  for  admission  to  hos- 
pitals, and  are  refused.  Our  municipalities  care 
for  tuberculous  individuals,  they  are  extremely  care- 
ful of  them,  and  the  finest  sanitaria  are  erected  to 
house  them;  but  the  unfortunate  individual  with 
syphilis  or  with  gonorrhea  is  em  outcast. 

I  would  be  in  favor  also,  in  cases  of  gonorrhea 
and  syphilis,  of  making  these  diseases  reportable, 
so  that  they  can  be  cared  for  and  be  under  super- 
vision as  well  as  those  of  the  professed  type. 

Dr.  Robert  H.  HeRBST  (closing  on  his  part)  : 
You  have  heard  a  great  deal  this  evening  about 
venereal  prophylaxis,  and  very  little  has  been  said 
with  reference  to  the  cure  of  the  disease.  I  judge 
many  of  you,  as  is  also  true  of  the  laity,  believe 
that  gonorrhea,  at  least  in  the  male,  should  be 
relegated  to  the  incurable  heap.  I  think  this  notion 
has  developed  because  we  as  a  medical  profession 
at  large  have  been  devoting  our  attention  to  the 
treatment  of  this  condition  in  the  male  largely  to 
the  lower  urinary  tract  and  have  sadly  neglected 
the  genital  tract  where  the  gonococcus  is  harbored 
and  carried  to  the  marriage  bed. 

Let  us  briefly  consider  the  pathology  of  the 
condition  in  the  male  after  it  has  gone  on  for  a 
number  of  months.  If  a  man  has  a  slight  ca- 
tarrhal discharge  from  the  urethra,  he  may  have 
infected  lacunae;  he  may  harbor  gonococci  in  the 
follicles  in  the  prostate  gland  or  the  seminal  vesicles. 
and  how  much  good  will  syringing  with  some  fluid 
do  in  these  conditions?  That  is  the  way  the  ma- 
jority of  males  are  treated  for  gonorrhea  today. 
If  we  eliminate  the  condition  of  infection  of  the 
lacunae  and  give  the  bladder-neck  cases  the  benefit 
of  instillations  and  attack  them  surgically,  if  neces- 
sary, where  the  seminal  vesicles  and  ducts  harbor 
these  organisms,  we  can  do  much  good.  Let  us, 
for  instance,  drain  the  vesicles  by  vesiculotomy  or 
make  an  opening  in  the  vas  and  medicate  with 
silver  salts  and  collargol. 

In  regard  to  the  operative  treatment  of  epidi- 
dymitis,  I   agree  with  what  has  been  said  that  if 

148 


we  simply  incise  the  epididymis  and  drain  it,  we 
will  see  a  recurrence  of  the  disease.  I  am  certain 
from  my  own  experience  that  if  we  incise  the  epi- 
didymis, drain  it,  and  take  care  of  the  rest  of 
the  genital  tract,  the  vas  and  seminal  vesicles,  and 
inject  some  solution  mto  the  vesicles,  we  will  not 
see   cases   of    recurrent    epididymitis. 

Dr.  Isaac  A.  Abt  (closing  on  his  part)  :  I 
am  very  glad  to  have  heard  what  Dr.  Eisenstaedt 
has  said  with  reference  to  the  use  of  ethyl  cuprein 
hydrochlorid  having  been  successfully  used  in  these 
cases  of  vulvo-vaginitis.  We  have  used  it  hypo- 
dermically  in  severe  cases  of  pneumonia  and  have 
had  some  favorable  results. 

Referring  to  the  question  of  Dr.  Kretschmer, 
I  feel  I  will  do  best  by  simply  saying  I  do  not 
know,  but  the  fact  is  and  it  is  a  striking  fact,  that 
there  are  so  few  complications,  and  there  are  so 
few  cases  of  ophthalmia  in  the  gonorrheal  infections 
of  infants.  It  seems  strange  that  the  organism 
should  have  a  selective  action  for  the  vulva  and 
vagina.  Then,  too,  we  know  that  once  infection 
has  taken  place  with  this  organism,  the  child  some- 
times prolongs  the  infection  by  manipulating  the 
parts  or,  to  be  plain,  by  masturbation.  The  child 
rarely  puts  the  fingers  in  his  eyes,  but  he  most 
often  puts  his  fingers  to  his  mouth,  but  very  seldom 
is  infection  there.  Why  there  are  so  few  cases 
of  ophthalmia,  and  why  complications  are  so  rare, 
I  am  at  a  loss  to  know. 

Dr.  L.  W.  Bremerman  (closing  on  his  part)  : 
That  portion  of  my  paper  relative  to  the  segre- 
gation of  prostitution  has  brought  forth  some  criti- 
cism, and  I  think  to  a  degree  some  just  criticism, 
but  I  think  the  criticism  of  my  stand  in  this  matter 
from  Drs.  Blount  and  Yarrows  is  absolutely  un- 
warranted. I  was  not  considering  segregation  from 
a  moral  or  immoral  standpoint,  but  from  the  stand- 
point of  venereal  infection.  I  am  sure,  those  who 
practice  genito-unnary  surgery,  or  who  specialize 
in  venereal  diseases,  in  taking  the  histories  of  their 
cases  will  find  that  the  men  who  come  to  them  in- 
fected with  gonorrhea  give  a  history  to  the  effect 
that  they  have  contracted  the  disease  in  a  large 
proportion  of  cases  from  other  than  professional 
prostitutes.  In  Guiteras'  recent  book,  he  quotes 
Fournier,  who  states  that  of  387  men  examined, 
they  contracted  gonorrhea  as  follows:  From  li- 
censed prostitutes,  1  2  cases ;  private  prostitutes,  44 
cases ;  mistresses  and  actresses,  1  38  cases ;  working 
women,  126  cases;  "private  snaps,"  41  cases,  and 
married  women,  26  cases. 

This  report  of  Fournier  shows  definitely  that  the 
licensed  prostitute,  from  the  standpoint  of  venereal 
infection,  is  much  less  dangerous  as  compared  with 
the  unlicensed  prostitute. 

I  thoroughly  agree  with  Dr.  Blount  that  the 
male  should  be  placed  in  the  same  class  as  the 
female,  and  vice  versa.  I  tried  to  show  that  dis- 
tinctly in   my   definition   of   a   prostitute,    including 

149 


both  male  and  female.  I  still  think  that  from  the 
standpoint  of  venereal  disease,  segregation,  properly 
and  carefully  carried  out,  with  strict  scientific  ex- 
aminations accurately  made,  is  aii  excellent  method 
in  dealing  with  this  problem.  Scientific  examina- 
tions are  not  those  shown  by  Dr.  Yarrows,  consist- 
ing in  a  physician  coming  in  once  a  week  or  once 
in  ten  days,  after  making  a  casual  examina- 
tion, giving  the  prostitute  a  certificate  to  the  effect 
that  she  is  free  from  venereal  disease.  She  might 
have  been  free  from  venereal  disease  when  the  card 
was  first  made  out,  but  may  have  been  exposed 
any  time  during  the  interim.  These  examinations 
should  be  made  carefully  and  scientifically;  the 
discharges  and  secretions  should  be  examined  mi- 
croscopically and  culturally,  and  if  the  women  are 
found  to  be  chronic  carriers  of  the  gonococci,  they 
should  be  segregated  in  hospitals  where  proper  treat- 
ment may  be  carried  out. 

Dr.  Blount:  I  would  like  to  ask  you,  in  the 
list  you  read,  whom  would  you  segregate?  Would 
you  segregate  actresses  and  working  women,  or 
whom  would  you  segregate? 

Dr.  BremeRMAN  :  The  question  is  a  very  per- 
tinent one,  and  if  it  can  be  done,  I  believe  that 
all  of  these  women  should  be  segregated  as  well 
as  the  men,  but  if  we  were  to  attempt  to  segregate 
all  men  who  are  carriers  of  the  gonococci,  I  am 
afraid  there  would  be  very  few  left  to  carry  on 
our  daily  vocations.  It  Is  a  serious  question  and 
one  which  should  be  threshed  out  thoroughly  and 
absolutely  from  a  scientific  standpoint.  I  believe 
that  if  the  male  is  properly  Instructed  in  regard  to 
knowing  when  he  is  cured,  and  the  general  prac- 
titioner or  the  doctor  is  so  instructed  that  he  can 
make  these  examinations  properly,  he  could  tell 
a  patient  when  he  is  free  from  all  infection  so  far 
as  being  a  carrier  is  concerned,  and  that  of  Itself 
would  reduce  to  a  marked  extent  the  prevalence 
of  gonorrhea.  If  men  will  not  refrain  from  sexual 
excitation  and  must  seek  sexual  gratification,  let 
them  seek  those  places  where  they  are  less  liable 
to  contract  disease,  namely,  in  licensed,  well  regu- 
lated, restricted  sanitary  districts  rather  than  take 
the  women  of  the  street  and  cohabit  with  them,  no 
matter  whether  they  be  actresses,  mistresses,  or 
working  women. 


150 


SOME   OBSERVATIONS   ON    PYELITIS 
IN  PREGNANCY.* 

By  J.   Clarence  Webster,   M.   D.,  Chicago,   HI. 

The  study  of  pyelitis  in  pregnancy  reveals  a 
number  of  points  worthy  of  special  consideration. 
The  literature  on  the  subject  is  rich  in  inaccuracies, 
inexact  statements  and  fanciful  speculations  regard- 
ing the  various  factors  which  are  concerned  in  the 
production  of  the  disease. 

Regarding  its  frequency,  available  data  are  not 
thoroughly  reliable.  In  the  past  there  has  been 
great  lack  of  careful  analysis  in  discriminating  be- 
tween the  following  classes  of  cases: 

I.  Those  in  which  the  disease  occurs  for  the 
first  time  in  pregnancy. 

II.  Those  in  which  the  disease  in  pregnancy 
is  merely  a  continuance  of  that  whch  was  known 
to  exist  when  gestation  began. 

III.  Those  in  which  it  is  merely  the  redevelop- 
ment of  a  condition  which  existed  at  some  period 
previous  to  pregnancy.  This  class  is  undoubtedly 
larger  than  is  generally  believed. 

In  many  cases  pyelitis  may  run  such  a  mild 
course  as  to  cause  no  symptoms  and,  therefore,  to 
be  unsuspected.  In  this  latent  condition  there  is 
a  tendency  to  occasional  exacerbations,  which  may 
occur  in  pregnant  as  well  as  in  non-pregnant  women. 

In  estimating  the  frequency  of  true  primary  pye- 
litis of  pregnancy,  therefore,  it  is  quite  evident  that 
an  almost  impossible  task  is  presented  even  to  the 
most  careful  observer  who  attempts  to  make  an 
analysis  of  a  large  number  of  cases.  Are  preg- 
nant women  really  more  prone  to  the  disease  than 
those  who  have  never  been  pregnant?  I  am  very 
sceptical  on  this  point  and  in  fact  do  not  believe  it. 
The  disease  is  practically  the  same  in  pregnant 
women  as  in  the  non-pregnant.  The  same  varieties 
of  infecting  organisms  are  found.  What  facts  are 
indisputable  as  regards  pyelitis  in  pregnancy,  which 
is  primary,  as  far  as  is  ascertainable? 

I.  The  disease  usually  begins  between  the  fifth 
and  eighth  months  of  gestation. 

II.  The  colon  bacillus  is  the  infecting  organism 
in  the  great  majority  of  cases.  This  is  also  true 
of  non-pregnant  women. 

III.  In  the  majority  of  cases  the  disease  occurs 
on  the  right  side,  though  it  may  be  bilateral  or 
limited  to  the  left  side. 

Various  speculations  have  been  current  regard- 
ing the  special  influences  exerted  by  pregnancy  in 
the  production  of  the  disease. 

I.  Obstruction  to  the  flow  of  urine  through  the 
ureters.  The  normal  relations  of  the  ureters  in 
pregnancy   are   very  well   known,   owing   to   many 


*Read  at  the  Joint  Meeting  of  the  Chicago  Gynecological 
and    Chicago    Urological    Societies,    March     17,     1916. 


rRepiinted    from    THE   UROLOGIC    AND    CUTANE- 
OUS  REVIEW,    May,    1916.] 

151 


elaborate  studies  of  the  cadaver  by  means  of  frozen 
sections.  Both  kidneys  and  ureters  are  subjected 
to  the  increase  in  intra-abdominal  pressure,  which 
becomes  more  marked  after  mid-term.  The  more 
tense  the  abdominal  wall,  the  more  marked  is  the 
pressure  of  the  uterus  against  the  posterior  parieties. 
In  a  primipara  it  is  greater  than  in  a  multipara. 
With  a  lax  abdominal  wall,  the  fundus  of  the  uterus 
tends  to  fall  forwards  when  the  woman  is  erect. 
The  more  separated  the  recti  abdominis  muscles, 
the  more  marked  is  this  tendency.  The  pregnant 
uterus  is  plastic  and  is  readily  moulded  by  struc- 
tures firmer  than  itself  with  which  it  comes  into 
contact.  Normally,  in  advanced  gestation,  it  is 
indented  by  the  vertebral  bodies  and  posterior  half 
of  the  pelvic  brim.  The  bowel  with  hard  fecal 
matter  or  tense  with  gas  easily  makes  an  impres- 
sion upon  it. 

Frozen  sections  show  that  this  moulding  may 
bring  the  uterus  into  very  direct  relationship  with 
the  ureters  where  they  cross  the  pelvic  brim  in  the 
hollow  on  each  side  of  the  promontory.  It  has 
often  been  stated  that  the  ureters  are  protected  by 
lying  in  these  hollows.  This  is  so  in  the  case  of 
certain  hard  tumors  but  not  in  the  case  of  the  preg- 
nant uterus  which  is  easily  moulded  and  may  thus 
press  directly  on  the  uterus.  The  pressure  is  in- 
creased the  larger  the  fetus,  the  more  abundant  the 
liquor  amnii  and  the  more  contracted  the  abdominal 
cavity.  Granting  these  anatomical  facts,  we  have 
absolutely  no  exact  knowledge  as  to  the  frequency 
or  degree  of  obstruction  to  the  flow  of  urine  in 
the  ureters. 

Dilatation  of  the  ureter  and  renal  pelvis  may  be 
found  in  pregnant  women  at  autopsy  or  in  abdom- 
inal operations,  but  the  condition  may  have  ex- 
isted previous  to  pregnancy.  There  is  no  evidence 
whatever  to  show  that  gestation  is  an  important 
factor  in  producing  these  conditions.  R.  Franz, 
of  Graz,  one  of  the  most  recent  writers  on  pyelitis 
of  pregnancy  (Medizinische  Klinilf,  Wien,  1 4 
Feb.,  1915),  gives  great  importance  to  obstruc- 
tion in  the  urinary  flow  (Harmtauung)  as  a  fac- 
tor in  its  production.  Another  writer,  Weibel, 
states  that  47  per  cent,  of  pregnant  women  have 
some  degree  of  backward  pressure  in  the  uterus. 
If  this  be  correct  and  if  Albeck  approximates  to  the 
truth  in  stating  that  pyelitis  occurs  in  only  0.67 
per  cent,  of  pregnant  women,  we  cannot  believe  that 
interference  wkh  the  urinary  flow  is  of  very  much 
importance  in  causing  the  disease.  Mirabeau  and 
others  refer  to  the  hyperemia  of  the  pelvic  viscera 
which  occurs  normally  in  pregnancy,  and  believe 
that  mucosal  swelling  in  the  bladder  and  ureter 
may  be  a  factor  in  producing  constriction  and  in- 
terference with  the  urinary  stream. 

Interferencie  with  the  ureters,  such  as  is  pro- 
duced by  intra-pelvic  swellings,  e.  g.,  solid  and 
cystic  tumors  and  tubo-ovarian  infective  masses,  in 
my   experience,   is   comparatively   rarely   associated 

152 


with  pyelitis.  Moreover,  in  a  very  considerable 
percentage  of  cases  of  hydroureter,  no  pyelitis,  what- 
ever is  found. 

Of  great  importance,  in  my  opinion,  is  the  ob- 
servation that  in  those  cases  in  which  there  is  the 
greatest  intra-abdominal  pressure,  e.  g.,  primiparity, 
hydramnios,  twin  pregnancy,  tumors  and  pregnancy 
there  is  no  greater  tendency  to  pyelitis  than  in  other 
gestation  cases. 

The  greater  frequency  of  the  disease  on  the 
right  side  has  been  widely  believed.  Yet,  we  must 
be  careful  about  accepting  statistics  with  regard  to 
this  point.  Without  ureteric  catheterization,  no 
one  is  competent  to  state  in  any  given  case  of  pyeli- 
tis whether  one  or  both  sides  are  affected.  Be- 
cause the  patient  has  pain  on  one  side  only  is  no 
proof  that  the  other  side  may  not  be  infected. 

Examination  of  the  ureters  per  vaginam,  while 
frequently  valuable,  is  not  sufficient  to  establish  the 
location  of  infection.  While  in  many  cases  of 
pyelitis  the  lower  ends  of  the  ureters  are  tender 
or  thickened,  in  others  this  is  not  the  case. 

Various  explanations  are  current  in  regard  to 
the  supposed  greater  frequency  of  pyelitis  on  the 
right  side.  Those  who  believe  that  interference 
with  the  urinary  flow  is  an  important  factor  refer 
to  studies  of  ureteral  dilatation  such  as  those  of 
Herzfeld.  This  investigator  has  tried  to  estab- 
lish a  different  anatomical  relationship  between  the 
ureters  and  iliac  vessels  on  the  right  and  left  sides. 
He  states  that  normally  the  ureters  are  somewhat 
protected  at  the  brim  by  crossing  the  bifurcation  of 
the  common  iliac.  When  the  latter  is  abnormally 
high  or  low,  there  is  more  risk  of  ureteric  compres- 
sion. Normally,  he  states,  the  right  ureter  is  more 
liable  to  pressure  than  the  left,  as  it  crosses  the  ex- 
ternal iliac  at  a  lower  level  and  enters  the  pelvis 
at  more  of  an  angle. 

This  explanation  seems  to  me  entirely  fanciful. 
I  have  been  unable  to  ascertain  any  relationship 
of  the  ureter  to  the  iliac  vessels  which  can  explain 
supra-pelvic  hydro-ureter. 

Franz  is  inclined  to  think  that  dextroversion  or 
dextrotorsion  of  the  uterus  may  explain  why  the 
right  ureter  is  more  frequently  affected  than  the 
left.  It  has  often  been  stated  that  the  uterus  ro- 
tates on  its  long  axis  as  it  grows  in  pregnancy,  most 
frequently  towards  the  right  so  that  the  left  border 
is  moved  forward.  In  a  long  series  of  investiga- 
tions made  years  ago  I  could  find  no  proof  of 
this.  Rotation  may  be  found  but  its  frequency 
is  unknown.  Clinical  determination  of  this  point 
is  not  reliable,  because  the  outline  of  the  uterus 
cannot  be  sufficiently  accurately  determined  in  re- 
lation to  the  landmarks  necessary  to  establish  the 
degree  of  rotation.  No  doubt  in  many  cases,  con- 
ditions described  as  rotation  have  been  only  the 
moulding  of  the  uterus  on  the  fetus  by  the  exam- 
ining hand.  Also,  rotation  has  been  described 
which  has  not  been  true  or  inherent,  but  only  acci- 

153 


dental,  due  to  displacement  by  distended  bowel 
or  bladder,  or  to  that  caused  by  old  adhesions  or 
cicatrices.  In  many  cases  rotation  found  in  preg- 
nancy is  only  the  continuance  of  the  condition 
which  existed  in  the  non-pregnant  state.  In  any 
case,  rotation  or  lateral  deviation  of  the  early 
months  is  of  very  little  importance  after  the  mid- 
term of  pregnancy  in  determining  pressure  against 
one  or  the  other  ureter.  Unless  there  is  a  very  lax 
abdominal  wall,  no  appreciable  movement  of  the 
pregnant  uterus  in  advanced  pregnancy  can  take 
place,  and  then  it  tends  to  fall  forward  when  the 
woman  is  erect. 

One  other  explanation  of  right-sided  pyelitis  is 
that  which  attributes  an  influence  to  dilatation  of 
the  renal  pelvis.  As  is  well  known,  this  is  more 
common  on  the  right  side  in  non-pregnant  women 
cUid  has  been  associated  with  the  greater  frequency 
of  mobility  of  the  right  kidney.  It  is  believed  that 
the  existence  of  this  condition  may  favor  the  de- 
velopment of  pyelitis  by  micro-organisms. 

Another  explanation  is  that  owing  to  the  tend- 
ency of  the  right  kidney  to  lie  lower  than  the  left, 
the  former  is  brought  into  closer  relationship  with 
the  colon  and  that  the  direct  passage  of  colon 
bacilli  through  the  tissues  (which  is  undoubtedly 
the  most  important  means  of  infection) ,  thereby, 
more  readily  takes  place  on  the  right  side.  This 
sounds  plausible,  but  is  not  satisfactory.  If  these 
anatomical  relationships  exist,  they  are  found  only  in 
the  early  months  of  pregnancy,  when  pyelitis  rarely 
develops.  In  the  late  months  of  gestation  the  large 
intestine  is  pushed  upwards  and  is  in  as  close  re- 
lationship to  the  left  as  to  the  right  kidney. 

Regarding  the  influence,  origin  and  mode  of  en- 
trance of  the  infecting  organisms  in  pyelitis,  there 
is  some  difference  of  opinion.  That  they  may  act 
without  any  previous  urinary  obstruction  in  the 
ureters  is,  of  course,  certain.  That  hydro-ureter 
may  be  secondary  to  infection  is  also  established. 
This  is  particularly  marked  when  the  lower  end  of 
the  tube  is  infiltrated  with  tuberculosis,  but  it  may 
be  due  to  the  activity  of  other  organisms.  Colon 
bacilli  are  the  most  common  cause  of  pyelitis. 
Streptococci,  staphylococci,  gonococci  and  tubercle 
bacilli  and  other  organisms  are  less  frequently 
found.  In  some  cases  more  than  one  variety  may 
be  found.  The  following  views  are  held  regarding 
the  invasion  of  the  pelvis : 

1 .  Entrance  from  the  vulva  through  urethra, 
bladder  and  ureter — probably  rare. 

2.  Passage  from  an  infected  bladder  through 
the  wall  into  surrounding  lymphatics  amd  thence 
upwards  along  the  ureters  to  the  kidney  pelvis. 
This  has  recently  been  urged  by  Bauereisen.  This 
is  difficult  to  prove  and  must  be  rare. 

3.  The  most  common  source  is  undoubtedly  the 
large  intestine.  From  it  the  colon  bacilli  may  pass 
in  local  disturbances,  e.  g.,  ulceration,  catarrh,  and 
probably  constipation,   and    possibly    in    generally 

154 


weakened  conditions.  Thence  the  organisms  may 
enter  the  blood  and  be  carried  to  the  kidneys,  or 
they  may  pass  directly  towards  the  kidneys  through 
the  lymphatic  connections  between  them  and  the 
large  bowel.  When  pyelitis  has  developed  it  may 
be  limited  to  the  pelvis  and  upper  ureter,  or  may 
extend  throughout  the  entire  length  of  the  latter. 
The  bladder  may  become  involved  but  frequently 
it  is  not  infected  or  only  to  a  slight  extent. 

4.  That  distant  focal  infections,  especially 
those  due  to  streptococci  and  staphylococci  may 
cause  pyelitis  by  blood  transmission  is  very  likely, 
though  definite  proof  has  not  been  established.  I 
have  had  one  case  in  which  an  infection  of  throat 
and  nose  was  followed  by  bilateral  pyelitis,  the 
same  organism,  a  streptococcus,  being  obtained  from 
both  diseased  tracts. 

The  symptoms  and  signs  of  the  disease  are  the 
same  as  in  non-pregnant  women.  In  some  cases  the 
patient  may  complain  only  of  malaise  and  slight 
fever,  without  any  pain.  The  fever  may  be  high 
and  may  be  accompanied  with  chills.  There  is 
often  aching  in  the  loins.  Frequently  attention  is 
first  called  to  a  pain  in  the  affected  side,  accom- 
panied by  fever,  nausea  or  vomiting ;  it  may  be  any- 
where along  the  urinary  tract.  In  some  cases  there 
is  frequency  of  urination.  Rarely  is  there  actual 
bladder  distress,  except  where  this  viscus  is  in- 
volved. When  the  disease  occurs  on  the  right  side, 
the  pain  may  simulate  that  found  in  appendicitis 
or  even  in  gall  bladder  disease.  Serious  mistakes 
have  been  made  in  diagnosing  these  cases  as  ap- 
pendicitis, cholecystitis  and  adnexal  disease  and  in 
opening  the  abdomen  for  the  relief  of  the  condi- 
tion. During  one  month,  a  few  years  ago,  I  was 
asked  to  operate  several  times  for  appendicitis  in 
pregnancy  after  the  sixth  month  where  acute  pyelo- 
ureteritis  alone  existed.  In  each  instance  vaginal 
examination  had  not  been  made  cuid  urinalysis  had 
been  neglected.  In  all  cases  these  two  procedures 
are  of  the  greatest  importance.  In  many  there  is 
very  definite  tenderness  along  the  lower  portion  of 
the  affected  ureter  which  may  be  so  thickened  as 
to  be  readily  palpable.  The  most  marked  outlining 
of  the  ureter  occurs  when  a  stone  is  impacted  and 
surrounded  by  fibrin  and  in  tuberculous  infiltration. 
In  the  urine  there  is  albumen  and  pus,  epithelium 
from  the  pelvis  of  the  kidney  or  ureter.  In  some 
stages  red  blood  corpuscles  are  found  and  when 
the  true  kidney  substance  is  involved,  there  may  be 
considerable  serum  albumen  and  casts.  The  quan- 
tity of  urine  tends  to  be  decreased  and  its  specific 
gravity  increased.  Microorganisms  are  usually 
abundant  except  possibly  in  the  very  early  stage  of 
the  disease,  and  of  course  variations  are  found  from 
time  to  time  in  long  protracted  chronic  cases.  Cys- 
toscopy and  ureteral  catheterization  are  rarely  ever 
necessary  to  establish  the  existence  of  the  disease 
but  may  be  helpful  if  it  be  thought  important  to 
determine  the  extent  of  the  urinary  tract  involved. 

1.5.5 


Treatment. 

The  treatment  of  pyelitis  is  the  same  in  preg- 
nant as  in  non-pregnant  women.  It  is  important 
that  it  should  be  thorough  and  careful,  so  as  to 
modify  the  disease  as  much  as  possible,  lest  any 
serious  development  should  occur  which  might  cause 
premature  labor  spontaneously,  or  call  for  its  in- 
duction. In  severe  pyelitis  there  is  undoubtedly 
an  increased  risk  of  this  complication.  In  the 
case  of  labor  the  risk  of  uterine  infection  from  the 
urine  is  considerable. 

Details  of  treatment  need  not  be  fully  specified. 
They  fall  under  the  following  divisions: 

1 .  Rest  in  bed  in  the  early  stages. 

2.  Soft  diet,  non-irritating  to  the  kidneys,  with 
free  liquids. 

3.  Administration  of  urinary  antiseptics. 

4.  Vaccine. 

5.  Local  applications  through  the  cystoscope 
and  ureteral  catheter. 

6.  Surgical. 

Of  these  the  most  widely  employed  are  the  first 
three  and  they  suffice  for  a  large  percentage  of 
cases.  With  the  best  of  care,  while  it  is  rare  that 
marked  pyonephrosis  results,  a  considerable  per- 
centage do  not  recover  completely  but  continue  the 
disease  in  a  chronic  form,  though  usually  mild  and 
subject  to  exacerbations. 

Autogenous  vaccine  treatment,  while  apparently 
often  helpful,  has  been  on  the  whole  disappointing. 
It  is  utterly  valueless  in  very  chronic  cases,  es- 
pecially where  marked  changes  have  occurred  in 
the  upper  ureter  and  kidney. 

Surgical  treatment  of  pyonephrosis  may  become 
necessary  in  pregnancy,  but  as  it  is  likely  to  be 
followed  by  a  chronic  discharge  in  the  lumbar 
region,  there  is  great  risk  of  puerperal  infection 
when  labor  occurs.  The  operation  should  always 
be  postponed  if  possible,  until  the  uterus  has  been 
emptied  and  the  puerperium  somewhat  advanced. 

Termination  of  pregnancy  for  the  purpose  of 
curing  a  pyelitis  is  not  to  be  considered  except  pos- 
sibly in  the  rare  instance  of  an  acute  development 
in  the  early  months.  Within  recent  years,  radical 
local  measures  have  been  applied  to  the  treatment 
of  pyelitis,  viz.,  catheterization  of  the  ureters  and 
irrigation  of  the  renal  pelvis.  In  acute  cases  these 
procedures  are  not  to  be  employed  as  a  rule,  be- 
cause of  the  trauma  likely  to  be  produced  m  the 
swollen  ureteric  mucosa.  I  have  known  bleed- 
ing to  be  caused,  resulting  in  the  formation  of  a 
fibrinous  clot,  which  caused  intense  suffering.  More- 
over, irrigation  or  application  of  antiseptics  is  only 
of  short  duration  and  can  be  of  little  influence  in 
destroying  the  microorganisms.  The  use  of  such 
methods  has  been  widely  abandoned  in  puerperal 
sepsis.  Why  use  it  in  a  tract  far  more  delicate 
than  the  uterus  and  much  more  difficult  of  access? 

156 


The  only  possible  benefit  to  be  obtained  from 
ureteral  catheterization  is  the  evacuation  of  urine 
accumulated  above  some  narrowed  part  of  the 
ureter.  I  would,  therefore,  employ  this  procedure 
if  marked  colicky  pain  suggested  obstruction.  In 
one  case,  I  relieved  a  patient  greatly — the  passage 
of  the  catheter  being  followed  by  the  escape  of  a 
spindle-shaped  fibrinous  clot  which  was  impacted 
in  the  ureter  close  to  the  bladder. 

In  chronic  pyelitis  irrigation  of  the  ureters  and 
application  of  antiseptics,  e.  g.,  silver  salts,  has 
been  very  little  employed  in  pregnancy.  The  re- 
sults of  this  form  of  treatment  have  been  disappoint- 
ing as  regards  effecting  a  permanent  cure  and  I 
am  not  in  favor  of  using  the  method  in  pregnant 
^\'omen. 


157 


COURSE  AND  PROGNOSIS  OF  PYELO- 
CYSTITIS  IN  INFANCY.* 

Bv  Clifford  G.  Grulee,  M.  D.,  Chicago,  111. 

It  is  peculiar  that  to  the  majority  of  general 
practitioners  pyelo-cystitis  in  infancy  is  almost  an 
unknown  condition.  This  is  repeatedly  brought  to 
the  mind  of  the  pediatrician,  and  time  after  time 
a  child  who  has  been  sick  several  weeks,  even 
months,  with  a  high,  irregular  temperature  and  no 
other  involvements  to  be  noted,  shows  upon  exam- 
ination of  the  urine  large  quantities  of  pus.  If 
the  condition  were  a  rare  one  we  could  explain  this 
lack  of  knowledge,  but  of  the  acute  febrile  affec- 
tions of  infants  it  must  rank  among  the  first  five 
or  six  in  point  of  frequency;  and  it  is  therefore 
of  great  importance  that  due  attention  be  paid 
to  it. 

Probably  the  chief  reason  that  this  condition  is 
not  recognized  more  frequently  is  that  the  symp- 
toms, as  a  rule,  do  not  point  to  the  urinary  tract. 
The  onset  is  usually  sudden  with  high  rise  of  tem- 
perature and  little  else.  Urination  is  not  noticed 
to  be  more  frequent  nor  is  the  urine  irritative.  In 
fact  the  chief  characteristic  aside  from  high  fever 
is  almost  entire  absence  of  physical  findings.  This 
is  so  marked  that  it  alone  should  lead  one  to  think 
immediately  of  urinary  infection. 

Following  the  onset  with  sudden  rise  of  tem- 
perature, the  fever  continues  usually  quite  irreg- 
ularly. Various  types  may  be  mentioned.  We 
have  in  some  instances  the  high  continuous  type  of 
temperature  ranging  from  104^  to  106",  never 
dropping.  This  may  lead  in  a  few  days  to  death. 
An  example  is  the  following : 

A  girl  baby,  age  10  months,  was  seen  by  me  on  the 
afternoon  of  the  23rd  of  November.  Six  days  previously 
the  mother  had  noticed  that  the  child  was  not  well;  fever 
was  noticed  but  no  other  symptoms.  The  following  day 
the  child  became  much  worse,  a  physician  was  called  who 
diagnosed  gastro-intestinal  disturbance;  the  following  day 
the  child  showed  no  symptoms  except  the  temperature  which 
ranged  from  104  to  106^;  she  was  very  apathetic;  the 
stools,  two  to  three  a  day,  contained  some  mucus  and  curds, 
probably  due  to  cathartics.  With  this  exception  the  history 
was  negative.  On  very  careful  examination  of  the  child 
no  physical  findings  were  to  be  met  except  those  which 
go  with  a  severely  toxic  infant  with  a  temperature  of  104 
to  106.°  On  the  evening  of  the  23rd  of  November  she 
entered  the  Presbyterian  Hospital  where  she  died  early 
the  morning  of  the  25th.  During  her  stay  in  the  hos- 
pital the  temperature  ranged  between  103.2°  and  106  ; 
during  the  last  24  hours  it  never  dropped  below  104  . 
The  blood  count  showed  3,800,000  reds,  70  per  cent, 
hemoglobin,  and  21,700  whites.  On  examination  of  the 
urine  there  was  found  albumen  and  a  number  of  pus  cells, 
10,200   on    the   first   count,   and    17,000   on   the   next   day. 

Much  more  characteristic  is  the  febrile  curve,  where  it  is 
one    which    shows    a    marked    tendency    to    rapid    rises    and 


*Read  at  the  Joint  Meeting  of  the  Chicago  Gynecological 
and    Chicago    Urological    Societies,    March    17,    1916. 


[Reprinted    from    THE   UROLOGIC    AND    CUTANE- 
OUS  REVIEW,    May.    1916.1 

158 


falls.  This  is  shown  quite  well  in  these  temperature  charts. 
You  will  see  that  it  is  not  uncommon  for  the  temperature 
to  rise  from  normal  to  103"  or  104^  within  a  very  few 
hours;  again,  a  drop  may  be  of  the  same  character.  This 
is  of  such  common  occurrence  that  a  history  of  rapid  rises 
and  falls  in  temperature  over  a  long  time  with  lack  of 
physical  findings  speaks  very  strongly  for  a  diagnosis  of 
pyelocystitis. 

In  observing  cases  in  the  hospital  it  is  often  seen 
that  the  temperature  will  remain  almost  within  the 
normal  limit  for  several  days,  and  sometimes  sev- 
eral weeks,  then  without  any  reason  which  can  be 
noted  the  temperature  will  show  a  sudden  rise  then 
fall  again  to  its  former  limit.  Almost  always  at  the 
times  when  the  temperature  rises  there  is  found  to 
be  an  increase  in  the  cell  count  of  the  urine.  The 
course  of  the  temperature  curve  is  usually  a  fair 
index  of  the  prognosis  of  the  case  in  acute  stages. 
As  the  temperature  declines,  the  quantity  of  pus  in 
the  urine,  as  a  rule,  becomes  less. 

Of  the  physical  findings  which  accompany  this 
disease  and  which  are  so  few,  those  of  the  skin 
are  perhaps  the  most  important.  At  the  time  of 
the  onset,  or  soon  thereafter,  and  usually  during 
the  acute  stages,  there  is  a  distinct  pallor  in  all 
probability  due  to  vasomotor  constriction  of  the 
peripheral  vessels.  There  is  a  marked  tendency  to 
a  dry,  sometimes  scaling,  skin  and  it  is  not  infre- 
quent to  see  transient  erythematous  reddening  more 
or  less  generalized.  Again,  not  uncommonly  in 
the  course  of  this  condition  there  is  found  to  be  a 
slight  but  distinct  reddening  of  the  pharynx  which 
may  lead  to  a  slight  dry  cough.  As  a  rule  the 
gastro-intestinal  symptoms  are  of  slight  degree, 
though  the  condition,  of  course,  may  lead  to  a  state 
of  marasmus  of  a  character  very  resistant  to  treat- 
ment. Usually  during  the  acute  febrile  stage  there 
seems  to  be  em  increased  number  of  stools  which 
are  frequently  green  in  color  and  may  contain  curds 
and  mucus.  Vomiting  at  times  is  a  symptom  but 
cannot  be  regarded  as  characteristic.  Sometimes 
when  the  condition  is  a  severe  one  it  is  possible  to 
palpate  the  lower  poles  of  the  kidneys;  this,  of 
course  is  more  frequently  found  true  on  the  right 
side. 

Of  prime  importance  in  this  condition  is  the  ex- 
amination of  the  urine.  In  the  very  early  stages 
in  all  the  cases  which  I  have  seen,  pus  is  not  pres- 
ent but  a  distinct  bacilluria  exists.  Within  24  to 
72  hours  the  pus  makes  its  appearance  and  is 
usually  present  in  large  amounts.  In  determining 
the  presence  of  pus  in  these  cases  it  is  never  neces- 
sary or  even  wise  to  resort  to  the  centrifuge.  A 
few  drops  of  urine  placed  on  a  slide  under  the  mi- 
croscope are  sufficient  to  confirm  the  suspicion  as 
to  the  presence  of  infection  in  the  urinary  tract.  In 
order  to  follow  the  course  of  the  disease  more  or 
less  roughly  and  to  determine  the  prognosis,  it  is 
of  value  to  count  the  number  of  pus  cells.  This 
may  be  done  with  the  usual  Thoma-Zeiss  hema- 
cytometer slide  in  much  the  same  way  as  the  white 

159 


cells  of  the  blood  are  counted-.  The  white  blood 
corpuscle  pipette  is  filled  up  to  "I"  with  the  dilut- 
ing fluid  (2  per  cent,  acetic  acid)  ;  the  pipette  is 
then  filled  up  to  1  1  with  urine.  The  entire  field  is 
counted,  9  large  squares,  the  number  multiplied 
by  11/9  which  gives  the  total  number  of  pus  cells 
per  cubic  millimeter.  I  have  found  this  method  of 
much  value  in  determining  the  progress  of  the 
treatment  and  feel,  that  in  a  general  way,  it  may 
be  depended  upon.  There  are  several  theoretical 
objections  to  this  procedure,  but  from  a  practical 
standpoint  it  is,  I  think,  of  value.  Albumen  is 
found  during  the  acute  stages,  due  probably  to  the 
pus  or  to  the  bacilli.  In  the  more  chronic  stages, 
after  the  condition  has  lasted  for  some  weeks,  it 
is  not  infrequent  to  find  red  blood  cells  in  small 
numbers  and  some  casts  in  the  urine. 

On  examining  bacteriologically,  the  causative  or- 
ganism, in  far  the  greatest  number  of  cases,  is 
found  to  be  the  colon  bacillus;  occasionally  strep- 
tococci and  more  often  staphylococci  are  found.  It 
is  of  a  great  deal  of  value  in  the  treatment  to  de- 
termine the  nature  of  the  organism.  In  case  this 
is  not  done  it  is  fair  to  assume  that  it  is  due  to  the 
colon  bacillus  until  it  is  proven  otherwise. 

I  recently  had  a  case  in  a  new-born  infant  caused 
by  the  bacillus  pyocyaneus. 

Prognosis. — Pyelocystitis  is  usually  looked  upon 
as  a  condition  which,  though  running  a  high  tem- 
perature, gives  an  almost  absolutely  good  prog- 
nosis. My  experience  with  these  cases  has  been 
quite  to  the  contrary.  While  it  is  true  that  a  large 
proportion  do  recover  without  serious  consequences, 
it  is  also  true  that  a  very  great  number  have  re- 
peated attacks  of  the  infection  and  that  not  a 
small  proportion  of  these  infants  succumb  to  the 
disease,  either  in  the  acute  stages  or  later.  It  is 
not  to  be  regarded,  in  my  opinion,  as  a  condition 
which  is  to  be  looked  upon  lightly  by  the  profes- 
sion, and  I  would  strongly  urge  that  more  attention 
be  paid  to  the  early  diagnosis,  since,  as  a  rule,  the 
results  to  be  obtained  bear  direct  relation  to  the 
time  after  the  onset  when  the  diagnosis  is  made. 
Death  in  these  cases  may  occur  during  a  very  acute 
onset,  such  as  the  case  previously  mentioned,  or 
the  condition  may  become  sub-chronic,  existing  for 
several  weeks,  the  infection  spreading  and  the  child 
gradually  succumbing  to  a  sepsis.  Or  the  condi- 
tion may  so  deplete  the  infant's  organism  that  a 
marasmus  of  parenteral  cause  is  produced  and  the 
child  succumbs  to  some  mtercurrent  infection.  Much 
more  likely  than  a  fatal  termination  is  the  tendency 
to  repeated  attacks,  and  no  man  who  has  seen 
many  of  these  cases  but  is  impressed  with  the  fact 
that  no  matter  how  thorough  the  treatment  may  be 
according  to  the  lines  laid  down  at  present,  re- 
peated attacks  are  very  common. 

The  attacks,  as  a  rule,  tend  to  become  less  se- 
vere but  one  can  never  feel  satisfied  that  a  case  of 
pyelo-cystitis  is  effectively  cured  and  that  there  is 

160 


not  present  at  least  a  tendency,  probably  a  focus 
of  infection,  which  will  result  in  a  second,  a  third, 
or  more  attacks.  How  long  this  can  last  I  do  not 
know.  We  have  a  definite  record  of  one  case 
which  entered  the  Presbyterian  Hospital  four  years 
ago,  has  been  back  repeatedly  since,  and  at  last 
accounts  showed  many  pus  cells  in  the  urine  and 
the  condition  was  such  that  we  were  unable  to  pro- 
duce any  effect  from  our  treatment. 

It  would  seem  to  me  not  at  all  unlikely  that 
some  cases  of  pyelo-cystitis  of  pregnancy  might  be 
due  to  this  condition,  and  that  the  infection  existed 
with  repetitions,  the  nature  of  which  had  not  been 
recognized  during  the  intervening  years. 

The  danger  of  a  chronic  nephritis  resulting  from 
pyelo-cystitis  in  infancy  is  relatively  slight.  Of  73 
cases  of  chronic  nephritis  in  infancy  and  childhood 
which  Heubner  was  able  to  collect  from  his  records 
(of  17,000  cases),  only  six  were  due  to  pyelo- 
cystitis,  in  his  opinion. 

In  closing  I  wish  to  lay  emphasis  on  the  fact 
that  pyelo-cystitis  is  a  common  condition  in  infancy, 
that  frequently  its  only  symptom  is  fever,  the  cause 
of  which  is  determined  only  when  the  urine  is  ex- 
amined ;  that  the  condition  is  one  whose  serious- 
ness has  been  greatly  underestimated,  one  which  not 
infrequently  leads  to  death,  and  which  has  a  marked 
tendency  to  repetition  in  a  large  proportion  of  cases. 


161 


SOME   FACTORS   IN   THE   DIAGNOSIS 

OF  KIDNEY  AND  BLADDER 

INFECTIONS.^ 

By  Arthur  H.  Curtis,  M.  D.,  Chicago,  III. 

Among  the  many  problems  worthy  of  considera- 
tion in  the  diagnosis  of  kidney  infections,  it  is  my 
purpose  to  discuss  only  certain  topics  of  special  in- 
terest. Cystoscopic  technic,  pyelography  and  some 
other  subjects  will  not  be  considered. 

Two  qualifications  are  essential  in  one  who  ranks 
as  a  competent  diagnostician  of  inflammatory  af- 
fection of  the  kidney.  Firstly,  a  mastery  of  cysto- 
scopic technic  is  vital.  Secondly,  a  thorough 
knowledge  of  bacteriology  and  associated  labora- 
tory procedures  is  needed  to  complement  the  cysto- 
scopic work.  The  former  need  is  now  given  w^ide- 
spread  recognition.  The  latter  is  not  so  generally 
recognized ;  yet  it  is  true  that  a  cystoscopist  who 
shuns  bacteriology  lacks  important  requisites  for 
thoroughly  efficient  service.  If  the  cystoscopist 
does  not  perform  laboratory  work,  he  should  not 
only  carefully  collect  urine  in  every  case,  but  should 
also  supply  the  bacteriologist  with  a  fitting  sum- 
mary of  the  clinical  data,  and  thereafter  observe,  in 
person,  the  results  obtained. 

The  History  and  Preliminary  Examination. — 
As  my  experience  increases  it  is  found  advisable  to 
put  forth  unusual  effort  in  tracing  the  origin  of  in- 
fection. We  all  have  a  tendency  to  look  too 
quickly  inside  the  bladder,  before  sizing  up  the 
situation  from  the  outside.  Five  extra  minutes  de- 
voted to  questioning  often  reveals  the  nature  of 
an  otherwise  baffling  case.  The  history  is  some- 
times the  only  means  of  detecting  a  neurosis  which 
has  masqueraded  as  a  kidney  infection ;  the  onset 
of  a  mysterious  infection  may  result  from  peculiar 
habits  of  life — such,  for  instance,  as  micturition 
only  once  or  twice  daily,  the  habit  of  only  partially 
emptying  the  bladder,  self-passage  of  catheters, 
and  other  abnormalities. 

Regular  examination  of  Bartholin's  glands,  pal- 
pation of  Skene's  ducts,  and  search  for  protruding 
urethral  granulations,  demonstrate  gonorrheal  in- 
fection in  many  supposed  neurotic  patients  with 
negative  urinary  and  cystoscopic  findings. 

Residual  urine  is  a  frequent  source  of  trouble. 
Elxamination  to  exclude  this  condition  is  notably 
necessary  in  cystocele  cases. 

The  Cause  of  ''Catheter''  Cystitis. — And  here  I 
wish  to  strongly  emphasize  one  belief.  Post-opera- 
tive and  post-partum  cystitides  have  long  been 
called    catheter   cystitis.      To    my    mind    it    is    er- 


*From  the  laboratory  department  and  gynecological  ser- 
vice of  St.  Luke's  Hospital.  Read  at  the  Joint  Meeting 
of  the  Chicago  Gynecological  and  Chicago  Urological  So- 
cieties.  March    17,    1916. 


[Reprinted    from    THE   UROLOGIC    AXD    CUTAXE- 
OUS    REVIEW.    May,    1916.] 

162 


roneous  to  place  the  chief  blame  on  the  catheter. 
Patients  who  develop  catheter  cystitis  suffer  from 
urinary  retention,  and  I  am  most  deeply  impressed 
that  retention  is  the  factor  of  prime  importance. 

Those  who  are  sceptical  I  ask  to  study  the  ques- 
tion with  this  in  mind.  They  will  find  that  catheter 
cystitis  in  patients  capable  of  thorough  evacuation 
is  of  rare  occurrence,  except  in  a  mild  and  transi- 
tory form. 

Cystoscopists  are  notoriously  careless  in  their 
technic.  Yet  I  venture  there  is  not  one  here  who 
can  recall  having  produced  a  cystitis  of  any  mo- 
ment, in  any  case  he  has  ever  examined.  Passage 
of  a  catheter  with  ordinary  cleanliness  and  care 
plays  at  the  most  a  minor  part,  and  is  not  the  es- 
sential cause  of  the  cystitis;  these  post-partum  and 
post-operative  patients  are  more  freuently  the  vic- 
tims of  urinarX)  stasis  cystitis  from  varying  degrees 
of  urinary  retention. 

Culture  Maying. — In  every  case  of  infection 
above  the  level  of  the  vesical  sphincter  the  sedi- 
mented  urine,  secured  by  catheter,  should  be  stained 
for  bacteria.  The  findings  so  obtained  do  much  to 
confirm  or  discredit  the  results  obtained  by  culture. 

This  is  not  a  timely  opportunity  for  discussion 
of  culture  media  and  t«^chnic.  But,  in  passing,  we 
should  recall  that  numerous  bacteria  flourish  only 
in  media  containing  blood,  ascitic  fluid,  or  animal 
tissue;  and  we  all  know  that  anaerobic  cultures 
are  needed  as  a  routine. 

Employment  of  a  tube  of  broth  as  a  single  agar 
slant  does  not  suffice.  Organisms  so  implanted 
produce  a  growth  which  gives  us  a  distorted  im- 
pression of  the  extent  of  infection.  In  fact,  stray 
contaminating  bacteria  can  overgrow  and  hide  the 
real  cause  of  trouble. 

Neither  is  implicit  faith  to  be  placed  in  plate 
cultures,  for  many  bacteria  grow  poorly  or  not  at 
all  by  this  method. 

It  is  high  time  for  us  to  attach  more  significance 
to  the  number  of  colonies  which  develop  in  the 
culture  media ;  for  it  is  necessary  to  determine  not 
only  the  character,  but  also  the  extent  and  the 
purity  of  growth,  in  order  to  form  a  rational  opin- 
ion of  the  disease  process.  This  means  that  iso- 
lation of  colonies  is  to  be  sought  for.  Knowledge 
of  the  amount  of  infection,  obtained  in  this  way, 
is  of  much  diagnostic  and  prognostic  value. 

Interpretation  of  Cultures. — Staphylococci  and 
certain  other  bacteria  are  bound  to  cause  frequent 
contamination.  One  gradually  learns  to  recognize 
most  of  these  invaders  and  to  correspondingly  dis- 
count their  significance. 

A  diagnosis  of  staphylococcic  pyelitis  can  be 
made  with  certainty,  but  this  must  be  done  with 
utmost  caution.  The  occurrence  of  a  pure  culture 
alone  is  extremely  untrustworthy  evidence.  It 
should  be  substantiated  by  the  presence  of  consid- 
erable numbers  of  staphylococci,  without  other  bac- 
teria, in  the  sediment  of  fresh  catheterized  specimens. 

163 


The  discovery  of  intracellular  cocci  is  an  added 
evidence  of  much  significance. 

Sometimes  a  contrary  result,  such  as  a  good 
growth  of  streptococci,  may  appear  when  least  ex- 
pected. Findings  of  this  nature  disproportionate 
to  symptoms,  can  not  be  accepted  without  inves- 
tigation. 

Limited  dependence  should  be  placed  on  meagre 
scattered  growth,  especially  when  this  contains 
colonies  of  different  kinds.  Yet  I  believe  the  fu- 
ture will  show  mixed  mfection  of  the  kidney  to  be 
more  common  than  now  credited.  Anaerobes,  es- 
pecially, are  often  present  in  mixed  cultures.  An 
illustration  is  afforded  by  a  kidney,  uncontaminat- 
ed  by  instrumentation,  aspirated  pus  from  which 
revealed  large  numbers  of  five  different  kinds  of 
organisms. 

Failure  of  growth  does  not  exclude  infection. 
In  the  presence  of  visible  inflammation,  negative 
cultures  are  inconclusive.  Just  as  pus  may  not  ap- 
pear constantly  in  the  urine,  so  I  have  several  times 
been  able  to  obtain  growth  only  at  irregular  times. 
And  although  present-day  technic  is  greatly  im- 
proved, some  bacteria  still  refuse  to  be  transplanted 
to  artificial  media. 

Diagnosis  from  Vaccines. — My  subject  does  not 
include  vaccine  therapy,  but  from  the  standpoint 
of  diagnosis  we  may  encroach  on  this  field.  Many 
absolutely  decry  the  use  of  vaccines.  Despite  this, 
I  am  looking  for  those  who  have  personally  made 
vaccines  for  a  considerable  number  of  patients  and 
have  given  them  a  fair  trial  without  some  success. 

Vaccines  must  be  made  with  detailed  care.  The 
first  dose  should  be  very  small  and  subsequent 
ones  gradually  increased  until  improvement  is  noted. 
Most  important  of  all,  that  dose  which  produces 
favorable  results  should  be  persisted  in  as  long  as 
improvement  continues. 

Success  from  vaccines  is  confirmatory  of  the  bac- 
teriologic  diagnosis.  Failure  suggests  an  incorrect 
bacteriologic  diagnosis  or  a  complicating  condition, 
such  as  stone,  tuberculosis,  or  obstructed  drainage 
of  pus  or  urine;  this  is  notably  true  of  infections 
with  strains  of  the  B.  coli  group. 

Animal  Injection. — The  injection  of  animals  is 
an  advisable  procedure  in  any  undiagnosed  case 
with  serious  mfection. 

We  should  not  limit  animal  injection  to  suspected 
cases  of  tuberculosis.  The  virulence  of  infections 
of  other  kinds,  with  some  indication  as  to  the  prob- 
able course,  is  often  well  shown  by  injection  of 
rabbits.  To  illustrate:  A  recent  patient  with 
double  pyelitis  had  symptoms  of  moderate  severity, 
with  large  numbers  of  B.  coli  colonies  in  pure 
growth  in  cultures.  There  was  no  reason  to  antici- 
pate an  unusually  severe  course.  Animals  injected 
with  the  fresh  cultures,  however,  died  almost  at  once, 
and  investigation  showed  that  1  / 1  00  of  the  usual 
lethal  dose  was  sufficient  to  produce  death.  These 
results  enabled  us  to  predict,   and  to  prepare  for, 

164 


an  unusually  severe  course.  Otherwise  we  would 
have  been  at  a  loss  to  account  for  the  subsequent 
serious  illness  which  ensued. 

Many  other  less  striking,  but  similar,  instances 
impress  me  that  animal  work  does  much  to  put  us 
in  closer  touch  with  conditions  which  we  ought  bet- 
ter to  understand  and  which  are  intimately  con- 
cerned with  the  welfare  of  our  patients. 

Also,  we  remember  recent  claims  of  remarkable 
affinity  of  bacteria  for  special  tissues,  an  affinity  so 
characteristic  that  lesions  which  occur  in  experi- 
mental animals  tend  to  reproduce,  in  miniature, 
those  existent  in  analogous  tissues  of  the  patient. 
Thus  far  in  my  experience,  however,  after  numer- 
ous and  repeated  attempts  to  obtain  such  results, 
it  has  been  possible  to  discover  little  more  evidence 
of  special  tissue  affinity  than  has  been  known  for 
a  considerable  period  of  time. 

Summary. — Urinary  tract  infections  are  not  ac- 
corded the  thorough  differential  bacteriological 
study  which  accurate  diagnosis  requires.  Cultures 
should  be  made  in  selected  media  in  such  manner 
that  isolated  colonies  develop;  this  permits  re- 
liable deductions  as  to  the  extent  and  purity  of 
growth. 

Post-operative  and  post-partum  infections  of  the 
bladder  are  largely  the  result  of  urinary  stasis;  con- 
taminated residual  urine  is  far  more  responsible 
than  is  the  passage  of  catheters. 

Extensive  use  of  experimental  animals  guards 
against  mistakes  in  diagnosis,  furnishes  an  index 
to  the  virulence  of  infections,  and  otherwise  gives 
us  a  better  knowledge  of  the  diseases  with  which 
Ave  have  to  deal. 


165 


TREATMENT  OF  PYELITIS.* 

By   Herman    Louis   Kretschmer,   M.   D.,   Chicago,   III. 

It  is  not  my  object  to  discuss  the  various  forms 
of  therapy  that  have  been  recommended  in  caises 
of  pyeHtis,  but  to  present  the  treatment  used,  and 
the  results  obtained,  in  this  series  of  cases. 

This  paper  is  based  on  a  report  of  38  cases. 
Of  this  number  1  6  cases  occurred  in  females  and 
1  9  cases  occurred  in  males,  and  in  3  the  sex  was 
not  stated.  Thirteen  cases  were  bilateral,  twelve 
occurred  on  the  left  side,  and  thirteen  occurred  on 
the  right.  Two  cases  occurred  during  pregnancy 
and  one  occurred  during  the  puerperium.  Most 
of  the  bacteriological  work  was  carried  out  by  Dr. 
Gaarde,  with  whom  a  detailed  report  will  be  pub- 
lished later.  The  colon  bacillus  was  found  in  all 
but  three  cases — in  two  staphylococcus  was  found 
and  in  one  a  streptococcus.  Pyelitis  due  to  the 
streptococcus  occurred  in  one  case  during  preg- 
nancy. 

Nearly  all  of  the  cases  belonged  to  the  group 
usually  designated  as  chronic  pyelitis.  The  question 
of  whether  pyelitis  can  exist  without  involvement 
of  the  renal  parenchyma  is  one  that  always  results 
in  a  good  deal  of  discussion.  Undoubtedly  the 
pyelitis  in  a  large  percentage  of  cases,  is  secondary 
to  infection  of  the  renal  parenchyma ;  this  in  many 
cases,  doubtless,  clears  up,  so  that  the  pelvis  and 
ureter  remain  the  seat  of  infection.  Cases  in  which 
this  has  occurred  come  to  us  usually  without  evi- 
dence of  previous  kidney  involvement,  and  are 
grouped  as  cases  of  pyelitis. 

In  selecting  cases  for  treatment  by  pelvic  lav- 
age, it  is  well  to  bear  in  mind  that  most  of  the 
cases  of  pyelitis  are  associated  with  organic  disease 
of  the  kidney,  pelvis  or  ureter,  such  as  stone,  stric- 
ture, dilatation,  tuberculosis,  etc.  This  group  of 
cases  requires  appropriate  surgical  treatment  and 
is  not  to  be  considered  in  this  paper.  Unless  a 
careful  selection  of  cases  is  made,  the  treatment 
must  result  in  failure;  for  example,  we  can  hardly 
hope  to  cure  pyelitis  due  to  a  stone,  T.  B.,  etc., 
with  this  form  of  treatment.  It  is  evident,  there- 
fore, that  cases  to  be  subjected  to  pelvic  lavage 
must  be  thoroughly  studied  before  instituting  tins 
form  of  treatment.  Roentgen  ray  examination, 
pyelography,  and  guinea-pig  inoculations  when 
necessary,  must  be  resorted  to  in  all  doubtful  cases. 
From  our  results  we  believe  that  we  are  justified  in 
stating  that  this  form  of  treatment  has  given  us 
very  prompt  results.  Whenever  prompt  results  are 
not  obtained,  it  is  reasonable  to  assume  that  the 
case   under   treatment   may   not   be   one   of   simple 


*Read  at  ihe  Joint  Meeting  of  the  Chicago  Gynecological 
and   Chicago  Urological   Societies,    March    17,    1916. 


[Reprinted    from    THE   UROIvOGIC    AND   CUTANE- 
OUS   REVIEW,    May,    1916.] 

166 


pyelitis,  but  may  have  one  of  the  previously  men- 
tioned etiological  factors. 

When  speaking  of  a  cure  it  is  well  to  state  just 
what  is  meant.  We  have  not  discharged  as  cured 
any  patient  who  did  not  fulfill  two  requirements; 
first,  the  urine  must  be  free  from  pus,  and  second, 
cultures  of  the  urine  obtained  by  ureteral  catheter 
must  be  sterile.  To  free  the  urine  of  pus  was  a 
relatively  easier  task  to  accomplish  than  it  was  to 
obtain  sterile  cultures.  We  have  repeatedly  seen 
the  urine  free  from  pus  and  a  disappearance  of  the 
clinical  symptoms  following  one  or  two  treatments, 
but  the  cultures  still  showed  the  presence  of  the 
causative  organism.  It  is  evident  that  too  much 
stress  cannot  be  laid  upon  this  fact,  and  it  is  easy 
to  understand  why  many  of  the  cases  relapse  if  the 
treatment  is  stopped  before  the  cultures  are  sterile. 
In  order  to  prevent  recurrences,  as  much  as  pos- 
sible, it  is  essential  to  relieve  any  focus  which  may 
be  the  cause  of  a  relapse.  In  the  cases  occurring 
in  women  for  example,  we  had  no  difficulty  in  ob- 
taining sterile  kidney  specimens  long  before  the 
bladder  urine  became  sterile.  It  would  seem,  there- 
fore, to  be  necessary  to  continue  treating  the  blad- 
der until  it  is  free  of  the  offending  microorganism. 
Bauereisen  and  others,  have  shown  the  direct 
lymphatic  connection  between  the  kidney  and  the 
bladder  via  the  lymphatics  of  the  ureter,  and  it 
seems  reasonable  to  assume  that  failure  to  cure  the 
bladder  infection  accounts  for  a  part  of  the  re- 
currence. 

In  males  we  are  impressed  with  the  great  fre- 
quency with  which  we  found  signs  of  an  associated 
prostatitis  and  seminal  vesiculitis.  In  one  of  the 
cases  in  which  the  patient  had  only  one  kidney, 
there  were  three  distinct  relapses,  due  we  believe, 
to  failure  on  his  part  to  carry  out  treatment  for  his 
prostatitis. 

From  our  experience  in  this  series  of  cases,  we 
believe  that  pelvic  lavage  gives  a  greater  number 
of  bacteriological  cures  in  a  shorter  space  of  time, 
than  any  other  form  of  treatment.  In  several  in- 
stances we  obtained  sterile  urine  after  one  or  two 
treatments  in  patients  who  had  been  upon  internal 
treatment  for  several  months. 

It  is  not  my  object  to  discuss  the  various  drugs 
that  have  been  employed  in  the  local  treatment  of 
pyelitis,  nor  to  discuss  the  many  drugs  recommend- 
ed for  internal  use,  but  to  state  briefly  the  technique 
as  it  has  been  employed  by  us  in  treating  this  series 
of  cases.  We  have  had  no  occasion  to  resort  to 
the  use  of  continuous  drainage  by  means  of  a  per- 
manent catheter  placed  in  the  ureter.  As  a  routine 
a  one  per  cent,  solution  of  silver  nitrate  was  used. 
In  only  one  case  did  we  use  silver  in  a  stronger 
solution  (2  per  cent.).  It  did  not  seem  to  make 
any  difference  in  the  rapidity  with  which  a  cure 
was  obtained.  We  cannot  see  any  advantage  in 
using  a  stronger  solution,  for  example  5  per  cent., 
as   recommended   by   Geraghty.      The   amount   of 

167 


solution  injected  varied  from  5  to  1  0  c.c.  As  an 
average  we  employed  between  5  and  7  c.c.  It 
is  of  the  utmost  importance  when  carrying  out  this 
treatment,  that  great  care  be  taken  to  avoid  a  rapid 
filling  of  the  pelvis,  and  not  to  use  too  large  amounts. 
If  the  injections  are  carried  out  slowly  and  one 
avoids  distention  of  the  pelvis,  there  is  practically 
no  pain,  except  that  incident  to  instrumentation. 
In  one  of  the  cases  the  pelvis  was  irrigated  with  30 
c.c.  of  boric  solution  before  injecting  the  silver  ni- 
trate solution.  This  was  carried  out  in  a  case  in 
which  there  were  large  amounts  of  thick  pus  flowing 
out  of  the  catheter.  Small  ureteral  catheters  were 
used,  so  as  to  allow  the  fluid  to  flow  from  the  pelvis 
down  the  ureter.  In  some  of  the  cases,  catheters 
were  passed  into  the  pelvis,  and  in  others  only 
about  half  way.  The  treatments  were  carried  out 
about  once  every  five  or  six  days. 

In  one  of  the  cases  of  pyelitis  of  pregnancy,  there 
was  associated  dilatation  of  the  kidney  pelvis,  so 
that  a  residuum  of  20  c.c.  of  urine  was  present. 
This  was  first  drained  away,  the  pelvis  was  then 
irrigated  with  a  solution  of  boric  acid  until  the 
washings  returned  clear,  after  which  the  pelvis 
was  injected  with  1  5  c.c.  of  a  I  0  per  cent  protargol 
solution. 

Autogenous  vaccines  were  used  in  about  one- 
half  of  the  cases.  The  internal  treatment  was 
carried  out  with  three  drugs,  which  were  adminis- 
tered as  follows:  During  the  first  week,  after  the 
diagnosis  was  made,  the  patients  were  given  about 
one  teaspoonful  of  bicarbonate  of  soda,  three  times 
a  day,  so  as  to  thoroughly  alkalize  the  urine.  Dur- 
ing the  second  week  the  soda  was  stopped,  and  in 
its  place  acid  sodium  phosphate  was  administered, 
so  as  to  thoroughly  acidify  the  urine.  During  the 
second  week,  that  is,  during  the  week  of  acid  urine, 
urotropin  was  given,  varying  in  amounts  from  30  to 
70  grains  per  day.  In  the  cases  in  which  the  uro- 
tropin produced  vesical  symptoms,  the  amount  was 
naturally  reduced.  This  form  of  internal  treat- 
ment was  kept  up  during  the  alternate  weeks,  as 
long  as  the  patient  was  under  treatment.  The  uro- 
tropin and  soda  bicarbonate  were  not  given  simul- 
taneously. 

Our  experience  with  other  drugs  has  been  too 
limited  to  permit  of  any  definite  statements  rela- 
tive to  their  merits. 

Pyelitis  following  pregnancy  can  be  treated  along 
the  lines  suggested,  and  in  fact  is  no  different,  nor 
need  to  be  managed  any  differently  than  any  other 
case  of  pyelitis.  When  the  pyelitis  occurs  during 
pregnancy  several  points  come  up  for  consideration. 
Cases  of  pyelitis  of  pregnancy  in  which  internal 
treatment  failed  were  formerly  handled  by  empty- 
ing the  uterus.  This  form  of  treatment  for  pyelitis 
during  pregnancy  is  based  upon  the  well-known 
fact  that  after  pregnancy  the  symptoms  of  pyelitis 
disappear.  Whether  or  not  the  pyelitis  really  is 
cured  is  another  point  for  discussion.     As  a  matter 

168 


of  fact,  many  of  these  cases  are  still  treated  in  this 
way.  With  the  institution  of  pelvic  lavage  in  the 
treatment  of  pyelitis,  and  its  application  in  the 
treatment  of  the  pyelitis  of  pregnancy,  one  is  justified 
in  stating  that  the  pregnant  woman  should  be  given 
the  benefit  of  this  form  of  treatment  before  the 
pregnancy  is  interrupted.  Surgical  attack  of  the 
kidney  for  pyelitis  of  pregnancy  should  only  be 
considered  after  a  failure  of  pelvic  lavage. 

Of  this  series  of  cases  we  were  in  a  position  to 
institute  pelvic  lavage  in  sixteen  and  to  carry  out 
the  treatment  to  completion  in  fourteen.  Two  cases 
left  before  they  were  discharged.  The  cases  in 
which  only  a  diagnosis  was  made,  and  those  in 
which  only  one  treatment  was  given,  are  not  con- 
sidered in  this  report  irrespective  of  the  fact  that 
the  clinical  symptoms  disappeared  and  the  urine 
cleared  up. 

The  report  embraces  only  those  cases  which 
were  discharged  as  cured. 

Two  of  the  1  6  patients  had  but  one  kidney,  the 
other  having  been  removed  by  nephrectomy.  Both 
were  discharged  with  urine  free  from  pus  and 
sterile.  In  one  of  these  two  cases  a  male  patient 
came  back  to  us  with  two  relapses.  He  suffered 
also  from  a  chronic  prostatitis  and  seminal  vesicu- 
litis, and  would  not  co-operate  with  us  in  carrying 
out  his  end  of  the  treatment  for  these  conditions. 

As  regards  sex,  there  were  five  females  and  ten 
males,  and  in  one  the  sex  is  not  stated. 

Number  of  Injections  Required. — In  five  cases 
sterile  cultures  were  obtained  in  two  injections. 
Four  cases  required  three  injections.  One  case  four 
injections.  In  one  case  six  injections  were  required, 
later  a  relapse,  which  required  two  injections. 

Failures. — In  these  sixteen  cases  there  were  two 
in  which  a  cure  as  previously  defined  was  not  ob- 
tained. One  of  these  occurred  in  a  case  of  staphy- 
lococcal pyelitis.  At  the  present  time  his  urine  is 
sterile,  but  it  is  not  free  from  pus.  The  other  was 
a  case  of  pyelitis  of  pregnancy  in  which  the  urine 
is  free  from  pus  but  not  sterile. 


169 


TRANSACTIONS 

Joint    Meeting    of    the    Chicago    Gyne- 
cological   AND    Chicago    Uro- 
LOGicAL  Societies. 

Held  March  17th.  1916.  with  the  President  of 
the  Chicago  Urological  Society,  Dr.  H.  L. 
Kretschmer,  in  the  chair. 

Dr.  J.  Clarence  Webster  read  a  paper  entitled 
"Pyelitis  During  Pregnancy."  (May  issue,  this 
journal.) 

Discussion. 

Dr.  N.  Sproat  HeaNEY:  One  point  em- 
phasized by  Dr.  Webster  has  always  been  very 
well  fixed  in  my  mind.  I  remember,  as  an  interne, 
the  number  of  cases  that  came  to  Dr.  Webster  to 
be  operated  upon  for  appendicitis  in  pregnancy 
that  proved  to  be  pyelitis.  Since  being  in  this 
special  work,  I  have  had  a  number  of  cases  of 
pyelitis  in  pregnancy  referred  to  me  under  the  diag- 
nosis of  appendicitis,  and  during  this  same  time  I 
have  never  seen  an  acute  appendicitis  in  pregnancy. 
Pyelitis  in  pregnancy  is  a  subject  which,  I  think, 
should  be  pounded  into  the  general  practitioner. 
The  diagnosis  of  pyelitis  in  pregnancy  should  be  em- 
phasized as  greatly  by  the  gynecologists  and  ob- 
stetricians as  is  appendicitis  by  the  general  surgeon. 
There  is,  of  course,  a  similarity  between  the  symp- 
toms of  both  affections. 

I  hesitate  to  venture  on  the  subject  of  treat- 
ment in  this  gathering,  as  to  whether  or  not  cathe- 
terization of  the  ureters  is  necessary  m  pregnancy. 
I  have  seen  patients  treated  both  ways,  and  have 
not  seen  a  case  that  I  thought  was  especially  bene- 
fited by  the  catheterization  of  the  ureters. 

One  thing  that  I  think  is  of  particular  import- 
ance in  the  treatment  of  pyelitis  in  pregnancy  is 
posture — not  only  having  the  patient  lie  on  one  or 
the  other  side  to  relieve  the  ureter  of  the  affected 
side  from  pressure,  but  by  having  the  patient  get 
in  the  knee-chest  position  frequently,  having  the 
air  enter  the  vagina,  so  that  the  uterus  may  ascend 
into  the  abdomen,  thus,  for  a  while  at  least,  al- 
lowing the  ureters  to  drain.  In  several  instances 
I  have  seen  an  immediate  disappearance  of  tem- 
perature. I  have  never  seen  a  case  of  pyelitis  in 
pregnancy,  treated  by  any  method,  in  which  the 
urine  entirely  cleared  of  all  pus  cells  and  micro- 
organisms while  the  pregnancy  was  still  existent. 
The  most  to  be  hoped  for  is  a  disappearance  of  the 
fever  and  pain,  and  lessening  of  the  amount  of 
pus.  The  "laboratory"  cure  of  the  patient  must 
be  made  after  the  pregnancy  has  ended. 

V  -Y  V 

Dr.  Clifford  G.  Grulee,  read  a  paper  entitled 
"Course  and  Prognosis  of  Pyelocystitis  in  Infants." 
(May  issue,  this  journal.) 


[Reprinted    from    THE    UROLOGIC    AXD   CUTANE- 
OUS  REVTKW,    May,    1916.] 

170 


Discussion. 

Dr.  Joseph  BrennemaNN:  In  estimating  the 
course  and  prognosis  of  pyelitis,  one  has  to  think, 
first,  of  the  pathology  of  the  condition,  and  try  to 
settle  this.  One  might  get  the  impression  from  the 
paper,  although  I  do  not  think  Dr.  Grulee  would 
want  to  give  it,  that  pyelocystitis  is  a  definite  entity, 
which  always  runs  a  certain  course,  very  variable 
at  times,  but  nevertheless  always  the  same  thing. 
Now,  that  really  is  not  true.  There  are  probably 
a  number  of  different  things  of  which  we  all  speak 
as  pyelocystitis,  which  have  only  one  thing  in  com- 
mon, namely,  pus  in  the  urine.  The  only  way  one 
could  tell  much  about  these  cases  would  be  from 
autopsy,  of  course.  The  vast  majority  do  not 
die,  therefore  we  have  very  few  autopsies.  More- 
over, in  those  cases  in  which  it  has  been  possible 
to  hold  autopsies,  the  findings  have  given  us  a 
wholly  misleading  idea,  because  it  is  only  a  very 
severe  type  that  dies. 

I  have  seen  probably  thirty  or  forty  cases  of  so- 
called  pyelocystitis  in  babies,  and  in  that  number 
there  has  been  only  one  death.  Finkelstein,  in  his 
series  of  something  like  eighty  cases,  speaks  of 
twenty  autopsies — that  is,  one-fourth  died.  The 
difference  between  the  two  is  simply  a  difference 
in  pathology.  The  cases  in  private  practice  occur 
under  favorable  circumstances;  those  in  foundling 
hospitals  are  entirely  different,  and  that  brings  us 
to  the  consideration  of  the  pathology.  A  number 
of  these  cases,  in  all  probability,  are  simply  cys- 
titis. That  was  Escherich's  idea.  He  was  the 
first  to  speak  of  these  cases.  He  thought  the  con- 
dition was  a  cystitis  due  to  a  colon  bacillus  infec- 
tion. Then,  later,  through  Heubner  and  others,  it 
was  made  rather  probable  that  those  cases  were  not 
simply  cystitis,  but  an  ascending  infection,  in  which 
there  was  a  cystitis  and  a  pyelitis.  More  recently 
authors  have  spoken  of  the  condition  as  pyelocys- 
titis, with  emphasis  on  the  pyelitis  rather  than  on 
the  cystitis.  Probably  those  cases  in  which  there 
are  rigors,  chills — which  practically  never  occur  in 
babies  except  in  pyelitis,  and  which  are  of  great 
diagnostic  value — high  temperatures  and  pallor,  are 
pyelocystitis,  with  the  emphasis  on  the  pyelo.  In 
the  thirty  or  forty  cases  which  I  have  seen,  all 
but  two  or  three  have  occurred  in  female  children 
and  this  fact  has  led  me  to  believe  that  these  cases 
are  due  to  ascending  infections,  occurring  during 
the  diaper  age.  If  one  sees  a  female  baby  that 
has  just  had  a  copious  liquid  bowel  movement,  that 
floods  that  whole  region,  it  is  easy  to  see  why  a 
certain  amount  of  feces  containing  colon  bacilli 
might  get  into  the  bladder  and  produce  an  ascend- 
ing infection.  Although  there  is  a  tendency  to- 
ward the  hematogenous  theory  of  infection,  I  still 
believe  that  the  great  majority  of  these  cases  are 
due  to  ascending  infection.  In  the  vast  majority 
of  these  cases  the  colon  bacillus  is  the  predominat- 
ing organism. 

171 


Then  there  is  a  third  group  of  cases — the  type 
found  in  foundling  homes,  in  which  there  is  not 
simply  a  pyelitis  and  cystitis,  but  a  pyelonephritis 
or  a  pyonephrosis.  In  these  cases  there  are  multiple, 
small,  cortical  hemorrhages.  Fifty  per  cent,  of 
the  autopsies  held  upon  these  cases  have  shown 
them  to  be  of  that  type,  and  nearly  all  of  them 
have  been  in  the  foundling  homes.  Those  babies 
are  in  poor  environment,  and  therefore  in  poor  con- 
dition, and  the  infection  is  a  graver  one.  It  is  a 
peculiar  fact  that  nearly  half  of  such  cases  have 
been  in  male  children,  and  one,  therefore,  can  see 
why  it  would  be  easy  to  believe  that  those  cases 
were  wholly  of  hematogenous  origin  and  had  very 
little  to  do  with  the  other  types. 

Then  I  think  there  is  still  another  class  of  cases, 
seen  especially  during  epidemics,  such  as  the  one 
occurring  here  last  winter  of  "grippe."  In  many 
of  these  cases,  if  we  examine  the  urine,  we  will  find  a 
large  number  containing  pus.  These  cases  clear  up 
quickly.  They  are  probably  not  colon  bacillus  in- 
fections. 

This  is  one  of  the  fields  in  medicine  that  re- 
quire investigation.  I  have  an  idea  that  we  will 
find  some  day  that,  the  ordinary  typical  case,  such 
as  Dr.  Grulee  has  described,  is  a  pyelocystitis  due 
to  the  colon  bacillus.  I  believe  we  will  find  that 
these  cases  which  occur  in  girls,  under  good  en- 
vironment— healthy  children,  always  practically 
under  one  or  two  years — are  due  to  ascending  in- 
fection, due  to  the  colon  bacillus,  and  that  these 
other  cases  are  either  an  infection  accompanying  a 
generalized  infection,  or  that  they  are  in  many  in- 
stances a  toxic  pyelitis,  possibly  without  any  or- 
ganisms at  all. 

When  one  comments  further  on  the  prognosis  and 
course  of  these  cases,  one  has  to  speak  for  a  mo- 
ment of  the  treatment.  Unfortunately,  we  do  not 
differentiate  these  cases  enough.  We  treat  them  all 
as  one  thing,  and  give  the  same  medication.  As 
Dr.  Grulee  emphasized,  that  ought  not  to  be  done. 
We  do  not  like  to  catheterize  these  cases,  and  a 
female  child  ie  not  well  adapted  to  give  a  speci- 
men not  containing  many  microorganisms,  conse- 
quently it  is  often  very  difficult  to  tell  whether  there 
are  organisms  present,  or  just  what  organism  is 
present.  It  is  difficult,  therefore,  to  tell  whether  the 
case  belongs  to  a  certain  category  or  not.  The 
colon  bacillus  infections  are  usually  very  easy  to 
tell  from  the  fact  that  they  occur  in  girls,  from  the 
presence  of  the  colon  bacilli,  and  from  other  things 
that  happen  in  connection  with  them.  Until  we 
know  more  definitely,  we  are  very  apt  to  have  a 
certain  routine  treatment,  and  there  we  differ  very 
widely  in  our  ideas.  Some  of  us  are  very  enthu- 
siastic about  urotropin.  I  personally  am  very 
strongly  in  favor  of  the  treatment,  recommended  by 
Thompson  and  still,  namely,  the  use  of  potassium 
citrate  in  doses  of  one  to  two  drams  a  day.  '  My 
usual   treatment  is   this:      I   give  potassium  citrate 

172 


for  a  while,  and  then,  if  the  patients  are  in  a  chronic 
stage,  or  latent  stage,  I  give  urotropin,  possibly 
salol,  and  then,  if  there  is  an  excerbation,  I  give 
potassium  citrate  again  because  I  think  it  has  a 
specially  favorable  action  at  such  times. 

As  to  the  number  of  cells  telling  us  anything 
about  the  prognosis  and  severity  of  the  disease,  I 
have  had  no  special  experience  with  that,  except 
that  which  comes  from  examining  a  lot  of  urines 
in  these  cases.  I  have  never  had  the  impression 
that  one  could  tell  much  from  the  number  of  cells. 
I  have  seen  cases  in  which  there  was  not  a  great 
deal  of  pus,  that  were  hard  to  cure,  and  others  in 
which  there  was  a  good  deal,  and  yet  they  re- 
sponded promptly,  and  vice  versa.  I  have  not  made 
accurate  observations  numerically,  so  cannot  speak 
very  intelligently  about  it. 

Finally,  it  is  well  to  emphasize  that  these  cases 
are  very  common.  They  are  almost  invariably 
overlooked,  as  Dr.  Grulee  has  said.  We  see  them 
over  and  over  again,  and  always  they  have  been 
diagnosed  as  meningitis,  or  pneumonia,  or  most  com- 
monly the  good  old-fashioned  "intestinal  disturb- 
ance," although  there  is  nothing  the  matter  with  the 
bowels,  or  stomach,  or  lungs,  or  brain,  or  anythmg 
else  except  the  urinary  tract. 

V  ^  ^ 

"Some  Factors  in  the  Diagnosis  of  Kidney  In- 
fections," by  Dr.  Arthur  H.  Curtis.  (May  issue, 
this  journal.) 

"Treatment  of  Pyelitis,"  by  Dr.  Herman  L. 
Kretschmer.     (May  issue,  this  journal.) 

Discussion. 

Dr.  G.  Kolischer:  It  is  impossible  to  dis- 
cuss this  subject  without  taking  into  consideration 
some  of  the  special  features  of  the  causative  path- 
ology. It  is  pretty  generally  accepted  among  com- 
petent observers  that  interference  with  the  urinary 
flow  is  one  of  the  primary  causes  of  pyelitis.  Tak- 
ing up,  for  instance,  the  pyelitis  in  pregnant  women, 
I  started  to  investigate  this  matter  systematically 
some  twenty  years  ago,  and  examined  two  hundred 
women  in  this  respect.  We  found  in  about  fifty 
per  cent,  pregnant  beyond  the  sixteenth  week,  that 
there  was  on  one  side  at  least  a  slowing-up  of  the 
urinary  flow,  and  the  intervals  between  the  urinary 
jets  were  extended  beyond  the  normal  length  of 
time.  In  about  one-quarter  of  these  cases  in  which 
the  slowing-up  of  the  urinary  flow  was  to  be  noticed, 
we  found  by  catheterizing  or  sounding  the  ureter 
of  this  side  that  there  was  an  obstruction. 

I  want  to  call  attention  to  one  very  important 
point,  namely,  invariably  in  all  of  these  cases  with 
obstruction  this  was  not  found  in  the  pelvic  but  in 
the  abdominal  section  of  the  ureter.  How  did  this 
obstruction  occur?  Of  course,  it  is  known,  as  Dr. 
Webster  stated,  that  the  uterus  during  the  later 
weeks   of  pregnancy  will   lean   to  one  side  or  the 

17.3 


other.  Now,  then,  if  an  obstruction  occurs  and  the 
uterus  leans  to  this  same  side,  we  can  assume  that 
the  uterus  in  toto  obstructs  the  ureter,  but  if  the 
uterus  is  bent  toward  the  other  side,  and  there  is 
an  obsruction  on  the  opposite  side,  then  one  is  en- 
titled to  assume  that  not  the  uterus  in  lolo  obstructs 
the  ureter,  but  that  a  fetal  part  presses  against  it. 

I  would  like  to  mention  at  the  same  time  that 
if  you  meet  an  obstruction  and  find  such  a  slowing- 
up  of  the  urinary  flow,  with  extension  of  the  in- 
tervals between  ejaculation  of  urine,  and  you  pass 
the  catheter  beyond  this  point  of  obstruction,  the 
intervals  between  ejaculation  are  not  shortened,  and 
consequently  one  is  entitled  to  assume  that  the  slow- 
ing up  of  the  urinary  flow  is  not  only  due  to  this 
obstruction,  but  also  to  an  edema  of  the  ureteral  mu- 
cosa, and  an  edema  of  the  pelvis  of  the  kidney,  lead- 
mg  to  reduction  of  the  contractability  of  this  renal 
pelvis. 

Suppose  we  are  entitled  to  believe  that  the  fetal 
part  obstructs  the  ureter,  then  we  can  resort  to  a 
very  simple  expedient,  namely,  placing  the  patient 
on  the  side  on  which  the  obstruction  occurs.  We 
know  if  a  fetal  part  rests  for  any  length  of  time 
against  the  wall  of  the  uterus,  that  that  part  of 
the  uterine  wall  will  contract  and  remove  the  fetal 
part  from  that  part  of  the  uterus.  In  several  of 
these  cases  the  patients  have  been  given  relief  by 
this  method  of  treatment. 

As  to  the  causative  pathology  so  far  as  the  fre- 
quency of  pelvic  infection  on  the  right  side  is  con- 
cerned, Frankenthal  was  the  first  one  to  call  at- 
tention to  the  connection,  especially  in  pregnant 
women,  between  appendicitis  and  renal  infection 
of  that  side.  It  was  later  on  taken  up  by  the 
French,  and  they  called  it  the  "Nephrite  appen- 
dicu  laire"  meaning  that  this  one-sided  nephritis 
is  based  on  acute  appendiceal  infection.  We  know 
that  the  lymphatics  of  the  right  side,  between  the 
cecum  and  ureter,  are  very  intimately  connected. 
It  is,  furthermore,  easily  explained  that  such  infec- 
tions occur  frequently  on  the  right  side,  because  the 
serosa  free  part  of  the  cecum  is  in  close  contact  with 
the  ureteral  sheath.  So  we  are  entitled,  now,  to  be- 
lieve that  most  of  the  infections  of  the  pelvis  of  the 
kidney  originate  in  the  large  intestine  and  lymphat- 
ics. If  we  have  to  deal  with  streptococcic  infec- 
tion of  the  kidney,  a  hematogenous  invasion,  we  find 
the  primary  foci  in  the  glomeruli,  furnishing  a  very 
characteristic  picture. 

If  the  condition  cannot  be  relieved  by  eliminating 
the  uterine  pressure,  then  there  is  only  one  thing 
to  do,  namely,  insert  a  ureteral  catheter  in  order 
to  drain  the  pelvis  of  the  kidney.  It  is  assumed  by 
many  authorities  that  there  is  no  pyelitis  without  dis- 
tention of  the  pelvis  and  that  the  normal  pelvis  has 
no  lumen  whatever.  If  there  is  a  lumen,  then  there 
is  pathology,  so  we  drain  the  pelvis,  and  by  leav- 
ing the  catheter  in  for  some  time  we  also  will  ac- 

174 


complish   the   disappearance   of   the  edema   of   the 
ureter. 

As  to  lavage  of  the  pelvis,  it  is  my  belief  that  it 
is  not  so  much  what  we  inject  into  the  pelvis,  but 
rather  the  fact  of  draining  the  pelvis — may  be, 
flushing  it  out,  the  mechanical  part  of  the  treatment 
— that  is  effective.  That  may  explain  the  dif- 
ferent reports  and  enthusiasm  of  different  authors 
regarding  the  different  solutions  used.  That  it'  is 
the  mechanical  effect  has  been  proven  by  another 
clinical  experience,  namely,  if  we  try  to  release  an 
impacted  ureteral  stone  by  injecting  oil,  we  quite 
often  relieve  the  patient  of  all  the  clinical  and  sub- 
jective symptoms,  although  the  stone  is  not  re- 
moved, simply  because  we  washed  away  the  debris 
and  established  free  drainage. 

As  to  vaccine  therapy,  while  the  original  en- 
thusiasm has  died  out,  yet  to  a  certain  degree,  it 
cannot  be  denied  that  the  combination  of  drainage 
and  vaccines  occasionally  furnishes  excellent  results, 
but  it  is  very  important  to  use  the  autogenous  vac- 
cines— autogenous  not  only  in  the  sense  that  the 
vaccine  is  cultivated  from  the  urine  of  the  patient, 
but  that  the  cultures  are  taken  from  the  place  of 
infection.  If  one  will  examine  carefully,  and  this 
is  especially  easy  to  do  in  women,  one  will  find 
that  the  flora  in  the  urethra,  the  bladder,  if  infected, 
the  ureter  and  pelvis  of  the  kidney  are  of  different 
characters ;  for  instance,  streptococci  in  the  urethra, 
staphylococci  in  the  bladder,  and  almost  invariably 
colon  bacilli  of  different  strains  in  the  ureter  and 
kidney.  If  you  take  urine  out  of  the  bladder  with 
the  catheter,  in  most  of  the  cases  you  will  get  a 
mixture  of  germs,  consequently  your  vaccine  is  not 
the  vaccine  that  you  want  to  use.  Therefore,  if 
you  want  to  make  vaccines  at  all,  you  have  to  take 
them  out  of  the  ureter  or  pelvis,  avoiding  contam- 
ination as  much  as  possible. 

As  to  the  most  heroic  treatment  of  pyelitis  and 
pyonephrosis  in  pregnant  women,  that  is,  the  pre- 
mature emptying  of  the  uterus,  that  depends  en- 
tirely on  two  conditions,  namely,  the  condition  of 
the  vascular  system  and  the  condition  of  the  heart 
muscle.  If  there  is  a  simple  valvular  disturbance, 
especially  if  compensated,  combined  with  a  pyone- 
phrosis or  pyelitis,  it  is  unnecessary  to  empty  the 
uterus.  But  if  we  have  to  deal  with  high  blood- 
pressure,  endocarditis,  and  pyonephrosis,  then  the 
indication  for  emptying  the  uterus  has  to  be  con- 
sidered because  we  know  that  with  the  progress 
of  the  pregnancy  and  with  the  eventual  delivery, 
we  have  an  added  strain  on  the  heart,  which 
the  myocarditis   heart   may  not  be   able  to  stand. 

As  to  pyelitis  in  children,  I  cannot  see  how  any- 
body can  diagnosis  a  cystopyelitis  or  pyelocystitis 
on  a  living  child  without  examining  the  bladder. 

As  to  the  number  of  pus  cells,  we  must  consider 
this.  Quite  often  exacerbation  is  coincident  with 
a  reduction  of  the  number  of  pus  cells,  because 
the  ureter  happened  to  be  blocked. 

175 


Pyelitis  in  children  is  a  very  important  affair  and 
I  am  fully  in  accord  with  the  two  pediatricians  as  to 
it's  dignity.     Permit  me  to  report  another  experience : 

Several  years  ago  I  presented  a  paper  before 
the  Gynecological  Society  on  pyonephrosis  in 
women,  and  reported  that  in  the  majority  of  cases 
where  I  was  compelled  to  remove  a  kidney  for 
pyonephrosis  I  was  able  to  trace  the  original  in- 
fection back  to  early  childhood.  I  would  like  to 
mention  at  the  same  time  that  so  far  as  I  know  the 
first  man  who  made  the  positive  statement  that  we 
cannot  consider  our  task  finished  in  treating  a  pye- 
litis when  the  pus  has  disappeared  from  the  urine, 
but  that  the  urine  must  be  sterile,  was  Dr.  I.  S. 
Koll. 

Dr.  Charles  S.  Bacon  :  I  have  seen  a  num- 
ber of  cases  of  pyelitis,  but  I  have  never  seen  a 
case  where  I  found  it  necessary  to  either  empty  the 
uterus  or  wash  out  the  pelvis  of  the  kidney  or  to 
make  ein  opening  into  the  ureters  or  pelvis.  But 
I  always  have  in  mind  the  idea  that  I  have  not 
seen  any  really  very  severe  cases,  and  I  am  liable 
to  meet  one  at  any  time. 

We  hear  every  little  while  the  proposition  that 
the  ureter  shall  be  opened  and  drained  from  the 
outside.  Some  two  or  three  years  ago  E.  P. 
Davis,  of  Philadelphia,  defended  that  proposition. 

Then  the  question  of  emptying  the  uterus  nearly 
always  comes  up  in  any  cases  of  any  severity  at 
all.  From  my  own  experience,  I  doubt  the  neces- 
sity. 

It  seems  to  me  that  if  we  will  put  the  patients  at 
rest  and  treat  them  in  a  conservative  way,  possibly 
with  vaccines — which  I  have  some  doubt  about, 
although  I  have  seen  some  results  from  their  use 
in  non-pregnamt  cases,  but  have  hesitated  to  use 
them  in  pregnant  cases — using  methods  of  clean- 
ing out  the  intestines,  which  seems  to  me  to  be  im- 
portant,  and  regulating  the  diet,  that  is  sufficient. 

There  seems  to  be  a  certain  wisdom  in  cathe- 
terization and  washing  out  the  kidney,  and  still 
there  is  question  as  to  the  permanency  of  the  re- 
sult. We  don't  consider  that  washing  out  cavities, 
as  a  rule,  accomplishes  a  great  deal,  and  so  this 
has  to  be  settled  by  experience. 

One  word  about  the  causation:  That  a  good 
many  cases  of  pyelitis  in  pregnancy  are  returns  of 
former  infections  is  pretty  well  established.  We 
know  the  great  persistence  of  these  infections,  and 
it  is  extremely  probable  that  an  ascending  infec- 
tion may  date  back  to  childhood.  Possibly  some- 
where between  twenty-five  emd  thirty  per  cent,  of 
the  cases  are  of  that  nature.  Many  believe  that 
the  infection  from  the  intestine  passes  in  some  way 
by  continuity  directly  through  the  serous  coat ;  this, 
of  course,  is  not  true.  As  Dr.  Kolischer  has  just 
described,  the  infection  passes  from  the  uncovered 
portion  of  the  mtestine  through  the  lymphatics  of 
the  ureter  to  the  kidney.  The  larger  part  of  these 
infections  are  explained  in  this  manner. 

176 


The  hematogenous  infections  I  feel  rather  shy 
about.  Without  raising  any  question  as  to  the  case 
described  by  Dr.  Webster,  I  should  suppose  that 
in  the  presence  of  a  streptococcus  infection  of  the 
kidney,  the  finding  of  streptococci  in  the  case  was 
no  proof  that  the  streptococci  came  from  some  dis- 
tant source.  I  should  be  very  sorry  to  believe  that 
we  must  hold  the  tonsils  and  teeth  responsible  for 
a  great  majority  of  these  pyelitic  infections. 

One  thing  I  would  like  to  ask  Dr.  Webster:  As 
Dr.  Kolischer  has  said,  the  obstruction  in  most  of 
these  cases  is  not  in  the  pelvic  part  of  the  ureter, 
and  I  cannot  understand  exactly  how  the  diagnosis 
can  be  made  by  a  vaginal  examination.  I  cannot 
see  just  the  importance  of  vaginal  examination  in 
making  the  diagnosis. 

Dr.  Irvin  S.  Koll:  I  hesitate  to  speak  upon 
this  subject  because  I  have  talked  about  it  so  often 
and  in  so  many  places.  I  feel,  when  discussing  the 
subject  of  pyelitis,  in  Chicago,  particularly  its  treat- 
ment, that  I  am  talking  in  hostile  territory.  It  is  a 
notorious  truism  that  one's  local  colleagues  are  al- 
ways loath  to  take  up  anything  that  deviates  from 
the  old,  hackneyed  routine.  Five  or  six  years  ago 
I  worked  upon  the  colon  bacillus,  and  its  infections 
in  the  urinary  tract,  and  found,  I  think,  a  therapeu- 
tic measure  that  I  have  published  a  number  of  times, 
namely,  the  use  of  the  solution  of  aluminum  acetate 
of  the  National  Formulary.  I  am  fortunate  in 
having  my  findings  borne  out  by  some  fifty  members 
of  the  American  Urological  Association — none  in 
Chicago;  fortunate,  because  I  feel  that  the  reports 
coming  from  these  men  mean  a  great  deal  possibly 
in  helping  me  verify  my  findings. 

It  is  a  biological  axiom  that  the  best  way  to  com- 
bat a  bacterium  is  to  change  the  action  or  the  re- 
action of  its  native  culture  medium.  We  know  that 
the  colon  bacillus  flourishes  in  the  lower  intestinal 
tract,  where  the  intestine  is  bathed  with  the  intes- 
tinal and  pancreatic  juices  which  are  strongly  alka- 
line in  reaction,  until  a  high  degree  of  fermentation 
takes  place,  when,  of  course,  it  becomes  acid,  but  it 
flourishes  before  in  the  alkaline  medium.  Notwith- 
standing the  fact  that  in  colon  infection  of  the  kid- 
ney cmd  bladder  the  urine  of  these  infections  is 
slightly  acid,  I  thought  that  if  we  increased  this 
acidity  we  might  get  rid  of  the  organism  more  quick- 
ly than  by  means  of  therapeutic  measures  that  we 
have  used  heretofore.  In  looking  about  for  a  drug 
that  would  have  some  penetrating  power,  that  would 
be  non-corrosive  and  at  the  same  time  strongly  acid, 
I  fell  upon  the  solution  of  aluminum  acetate. 

I  am  strongly  opposed  to  drawing  too  definite 
conclusions  from  what  we  find  in  the  test-tube  in 
the  laboratory,  because  it  is  a  long  way  from  the 
laboratory  to  the  clinical  patient,  yet  we  must  base 
some  conclusions  upon  our  laboratory  findings.  The 
time-honored  nitrate  of  silver,  first  in  its  very  weak 
solution,  IS  shown  bacteriologically  in  the  test-tube 
to  have  little  or  no  effect  upon  the  colon  bacillus 

177 


when  it  is  virulent.  In  the  tissues  it  has  practically 
no  penetrating  power. 

I  know  some  of  our  capable  men  do  not  believe 
in  the  penetrating  power  of  drugs  in  the  tissues.  I 
don't  think  this  conclusion  is  definitely  borne  out 
by  a  number  of  other  very  good  investigators,  how- 
ever. I  do  think  we  have  some  penetration  of  tissue 
by  drugs. 

The  use  of  nitrate  of  silver  in  strong  solution  is 
distinctly  corrosive,  consequently,  instead  of  getting 
a  penetration  of  tissue,  the  superficial  layer  is  cor- 
roded, and  I  will  venture  to  say  that  should  I  com- 
pare my  results  m  colon  infections  treated  with  al- 
uminum acetate  with  those  treated  with  nitrate  of 
silver  and  other  drugs,  you  would  find  that  the 
number  of  treatments  necessary  to  rid  a  urine  of  the 
bacterium — and  that  is  the  all-important  point — is 
much  less.  With  the  use  of  water  and  rest  in  bed, 
the  clinical  symptoms  will  disappear,  but  that  is 
not  a  cure.  It  is  a  long  way  from  a  cure.  Just 
as  long  as  you  have  a  bacterium  in  the  urine,  just 
so  long  you  run  the  chance  of  getting  a  recurrence, 
and  you  are  going  to  get  it  sooner  or  later. 

Some  subsequent  work  on  the  pathology — ex- 
perimental infections, — of  colon  infections  of  the 
kidney  leads  me  to  make  a  very  definite  statement, 
namely,  that  there  is  no  such  thing  as  a  pathological 
entity  of  pyelitis.  It  is  always  a  pyelonephritis. 
The  pathology  never  remains  in  the  pelvis  of  the 
kidney,  but  always  extends  into  the  parenchyma. 
That  is  the  reason,  I  think,  that  so  often  there  is  a 
failure  in  our  therapeutic  results  that  ultimately  will 
lead  us  to  surgical  interference. 

Dr.  Emil  Ries:  I  wish  to  emphasize  an  im- 
pression which  I  have  gained  here,  namely,  the  gen- 
eral feeling  that  we  know  nothing  about  pyelitis 
(laughter),  and  that  we  have  all  come  to  learn. 
I  regret  that  I  cannot  go  home  with  the  comfort  of 
feeling  that  the  question  is  settled.  Far  from  it. 
The  theories  which  have  been  brought  out  are  not 
new,  and  those  that  are  old  are  not  good.  For 
instance,  it  has  been  brought  out  that  the  most  fre- 
quently found  infection  of  the  pelvis  of  the  kidney 
is  due  to  the  colon  bacillus,  and  we  have  been  told 
that  the  colon  bacillus  migrates  from  the  colon,  as- 
cending through  the  healthy  wall,  gets  into  the 
lymphatics,  and  passes  along  the  lymphatics  of  the 
ureter  up  into  the  pelvis  of  the  kidney  and  there 
begins  its  destructive  work.  Now  who  has  ever 
seen  a  colon  bacillus  that  was  so  good-natured  that 
it  would  start  from  one  place,  go  to  another  along 
the  lymphatics,  still  continuing  harmless,  and  sud- 
denly appear  in  a  third  place,  for  instance  the  pelvis 
of  the  kidney  and  there  behave  badly?  How  do 
you  explain  that  the  colon  bacillus  can  start  out 
through  a  healthy  bowel  wall  and  go  through  half 
a  foot  of  tissue,  never  leaving  a  trace  behind,  and 
then  suddenly  start  to  be  pathogenic  in  the  pelvis 
of  the  kidney?  There  seems  to  be  some  break  in 
the  theory  somewhere. 

178 


On  the  other  hand,  we  have  been  assured  that 
there  is  frequently  great  difficulty  in  differential 
diagnosis  between  appendicitis  and  pyelitis;  in  fact, 
that  the  symptoms  are  so  similar  that  it  is  often  dif- 
ficult to  make  a  differential  diagnosis.  On  exam- 
ining a  great  number  of  appendices  that  have  been 
removed  with  malice  aforethought  as  normal  in 
the  course  of  laparotomies  for  other  purposes,  I 
have  found  that  a  great  many  of  these  appendices 
that  looked  perfectly  harmless  are  by  no  means 
normal,  even  if  removed  with  the  greatest  possible 
care,  so  as  not  to  injure  them.  I  have  found  that 
the  epithelium  is  damaged  in  many  places.  The 
appendix,  being  a  rudimentary  organ,  very  often  is 
not  absolutely  normal.  You  frequently  find  de- 
fects in  the  mucosa,  and  through  these  defects  there 
is  opportunity  for  the  germs  contained  in  the  ap- 
pendix to  invade  the  underlying  tissue.  But  is  it 
our  experience  that  from  there  the  colon  bacillus, 
the  most  frequent  inhabitant,  would  go  on  and 
make  trouble  in  a  distant  organ,  or  is  it  our  experi- 
ence that  most  frequently  the  appendix  itself  be- 
comes the  seat  of  trouble?  I  should  say,  usually  the 
appendix  becomes  the  seat  of  noticeable  trouble. 
However,  assuming  that  such  an  appendix  admits 
the  colon  bacillus  to  the  underlying  tissues,  and 
thereby  to  the  lymphatics,  is  it  not  the  logical  thing 
to  cut  the  Gordian  knot  by  removing  that  appendix 
in  addition  to  your  other  treatment? 

We  have  frequently  heard  discussions  of  bacil- 
luria  preceding  the  pyuria  of  pyelitis,  and  this  is  a 
very  much  to  be  desired  discussion  and  investiga- 
tion, namely,  as  to  the  length  of  time  for  which  a 
bacilluria  can  exist  without  causing  symptoms,  until, 
in  consequence  of  stagnation  in  the  urinary  system, 
produced,  for  instance,  by  pregnancy  and  the  pres- 
sure of  the  fetus,  the  bacilluria  develops  into  a 
pyuria  and  pyelitis.  We  have  no  exact  knowledge 
on  these  points.  However,  from  many  observa- 
tions it  seems  likely  that  if  not  all,  then  at  least 
very  many  of  these  patients  who  later  on  show 
pyelitis  originally  have  had  a  bacilluria.  Where 
do  they  get  their  bacilli?  How  do  the  bacilli  gain 
access  to  the  rest  of  the  body,  broadly  speaking? 
Possibly  through  the  appendix,  with  its  microscopic- 
ally small  defects.  Not  likely  through  the  tonsils 
or  teeth,  because  they  are  not  usually  inhabited  by 
the  colon  bacilli.  If  that  is  correct,  and  you  find 
the  patient  with  a  mild  pyuria,  or  even  a  bacilluria, 
to  cut  the  Gordian  knot  by  removing  that  appendix 
as  to  remove  the  tonsils  for  similar  reasons.  I  have 
acted  on  that  principle  occasionally,  and  can  re- 
port the  case  of  a  lady  who  is  now  in  the  eighth 
month  of  pregnancy  on  whom  I  operated  when 
she  had  a  slight  pyelitis  in  the  third  month  of  preg- 
nancy. I  removed  the  appendix.  Examination  of 
the  appendix  revealed  very  minute  lesions,  enough 
to  admit  bacteria  to  the  underlying  tissues.  The 
pyuria  disappeared  entirely  after  the  operation. 
She  has  not  even  a  bacilluria  now.     I  have  done  the 

179 


same  thing  in  other  cases,   with  successful   results. 

One  other  thing:  I  would  like  to  observe  these 
cases  for  about  ten  years,  because  most  of  the  cases 
of  pyuria  which  are  cured  of  the  discharge  of  pus 
still  retain  bacilli,  and  where  ultimately  even  the 
bacilli  have  disappeared,  and  the  cases  seemed  per- 
fectly normal  for  some  time,  the  condition  has  re- 
curred months  and  years  afterwards.  It  seems  to 
be  one  of  the  most  difficult  things  to  cure  a  case  of 
bacilluria  completely,  and  those  who  have  had  oc- 
casion to  observe  their  cases  for  years  will  probably 
make  the  same  observation. 

Now,  as  to  the  question  of  drugs  affecting  the 
bacilli  in  pyelitis,  which  was  raised  by  Dr.  Koll. 
He  and  I  have  had  several  discussions  on  this  point. 
From  what  we  know  about  the  penetration  of  disin- 
fectants (I  ^yill  only  speak  of  disinfectants)  in  any 
field  of  surgery,  we  have  come  to  a  point  where 
none  of  us  believe  in  it.  How  can  anybody  prove 
that  any  of  these  disinfectants  penetrate,  or,  if 
smeared  on  the  surface  will  reach  the  deeper  layers? 
All  the  experiments  that  have  been  made  with 
blocks  of  agar-agar  or  such  substcmces  do  not  prove 
a  thing  for  the  living  body. 

Dr.  H.  W.  Plaggemeyer,  Detroit,  Mich,  (by 
invitation)  :  I  wish  to  mention  one  case  in  regard 
to  Dr.  Webster's  paper  and  Dr.  Heaney's  discus- 
sion. This  patient  was  a  multipara,  I  saw  with  Dr. 
Peterson,  of  Ann  Arbor,  six  weeks  ago,  who  was 
sent  in  with  the  diagnosis  of  appendicitis.  At  that 
time  I  could  find  no  rigidity  over  McBurney's  point, 
but  did  find  rigidity  over  the  back.  On  catheter- 
ization, which  was  done  with  some  trepidation,  a 
fairly  well-defined  hydronephrosis  was  found  of 
25  c.c,  with  definite  colon  infection.  This  was, 
of  course,  drained,  and  no  other  therapy  employed. 
The  patient  has  gone  on  now  to  about  term  with  no 
recurrence  of  the  symptoms.  Whether  relief  was 
due  to  the  mechanical  removal  or  not,  I  cannot 
say. 

I  would  like  to  ask  Dr.  Brennemann  if,  in  cases 
of  apparent  hematogenous  infection,  he  has  noticed 
any  preponderance  of  kidney  pelvis  cells  over  the 
relative  amount  of  cells  in  the  urine?  I  have  noticed 
this,  and  wondered  if  others  had  also.  I  wondered 
if  it  would  be  of  any  special  value  in  leading  to 
the  cause  of  the  infection,  if  the  cell  relationship 
between  hematogenous  infection  and  infection  from 
below  could  be  standardized  in  any  practical  way. 

Dr.  Gustav  Kolischer:  Dr.  Ries  asked 
why  the  colon  bacillus  loses  its  good  nature  all  of  a 
sudden  in  the  appendix  and  instead  of  producing 
an  inflammation  of  the  cecum,  travels  to  the  kidney. 
Why  does  the  streptococcus  in  the  blood  produce 
a  malignant  phlegmon  somewhere  else  and  not  al- 
ways an  endocarditis?  We  know,  from  post-mor- 
tem findings  after  animal  experiments,  that  the  colon 
bacillus  will  travel  through  the  bowel  and  enter  the 
lymphatics.  This  has  been  proven  by  Bauereisen, 
Eisendrath,  and  others.      That  germs  occasionally 

180 


lose  their  good  nature  is  very  well  known.  Why 
does  a  streptococcus  for  years  and  years  lead  a 
saprophytic  existence  in  the  vagina,  and  all  of  a 
sudden  flare  up  and  become  virulent.  Is  it  the 
privilege  of  a  streptococcus?  And  if  there  arc 
such  minute  lesions  in  the  appendix  as  Ries  men- 
tioned, is  there  not  a  possibility  that  this  colon  ba- 
cillus may  travel  up  to  the  kidney? 

Dr.  L.  W.  Bremerman  :  I  cannot  allow  one 
statement  made  by  Dr.  Curtis  to  go  into  the  records 
unchallenged,  namely,  that  the  cystoscopist  is  notori- 
ously careless  in  his  technic.  I  have  seen  a  great 
many  cystoscopists  work — possibly  in  every  city  in 
this  country — -and  it  has  been  my  observation  that 
they  are  notoriously  careful  in  their  technic.  I  be- 
lieve that  most  men  in  this  specialty  realize  that  the 
process  of  cystoscopy  and  ureteral  catheterization 
should  be  considered  as  a  major  surgical  procedure, 
and  every  precaution  is  used  in  performing  these 
operations  that  is  used  in  performing  a  major  ab- 
dominal operation. 

Dr.  J.  Clarence  Webster  (closing  the  dis- 
cussion on  his  part)  :  I  wish  to  make  clear  certain 
points  which  have  been  referred  to  by  various 
speakers.  Dr.  Bacon  evidently  did  not  quite  un- 
derstand my  remarks  m  reference  to  the  palpation 
of  the  ureters  by  vaginal  examination.  In  normal 
conditions  it  is  practically  impossible  to  feel  the 
ureter  with  the  finger.  When,  however,  it  is  in- 
flamed, its  course  may  be  determined  for  nearly 
two  inches,  either  by  vaginal  or  rectal  examination. 
When  the  wall  of  the  ureter  is  thickened,  it  may  be 
felt  very  distinctly.  This  is  very  characteristic  of 
tuberculous  infiltration,  but  is  also  found  when  the 
infection  is  due  to  other  organisms. 

In  many  cases  of  pyelitis  the  lower  end  of  the 
ureter  is  infected,  though,  of  course,  this  is  not  al- 
ways the  case. 

Dr.  Kolischer  has  referred  to  the  pressure  of  the 
fetus  as  aji  influence  in  causing  interference  with 
the  flow  of  urine  through  the  ureters.  Many  years 
ago  this  factor  was  considered  important  by  various 
workers  who  were  trying  to  explain  the  causation  of 
eclampsia.  Inasmuch  as  the  fetus  is  a  portion  of 
the  uterine  swelling  of  pregnancy,  it  shares  in  the 
production  of  the  general  increase  in  intra-abdominal 
pressure,  but  I  place  no  importance  on  the  state- 
ment that  the  fetus  may  interfere  with  the  flow  of 
the  urine  through  the  ureter  by  pressing  directly 
against  it.  The  attitude,  position  and  presenta- 
tion of  the  fetus  change  loo  frequently  in  pregnancy 
to  cause  marked  or  long-continued  pressure  against 
the  ureter. 

Dr.  Kolischer  believes  that  backward  urinary 
pressure  (Harnslauung)  is  an  important  etiological 
factor  in  the  production  of  pyelitis.  If  it  is,  is  it 
not  remarkable  that  the  disease  is  not  more  common 
in  pregnancy?  It  is  highly  probable  that  backward 
pressure  as  a  result  of  the  development  of  the  preg- 
nant uterus  occurs  in  some  degree  in  a  large  per- 

181 


centage  of  pregnant  women — in  a  far  greater  per- 
centage of  cases  than  those  in  which  pyeHtis  occurs. 

Dr.  Bacon  has  spoken  with  regard  to  the  in- 
fluence of  focal  infections  in  causing  pyelitis.  I 
am  of  the  opinion  that  these  are  of  more  importance 
than  has  hitherto  been  considered,  both  in  pregnant 
and  non-pregnant  women. 

I  have  had  very  clear  evidence  of  pyelitis  being 
caused  by  a  streptococcus  from  a  nose  and  throat 
infection.  The  bacteriology  of  the  case  was  care- 
fully investigated  by  Dr.  Rosenow.  It  is  possible 
that  most  of  the  cases  of  non-colonic  pyelitis  may 
be  caused  by  distant  focal  infections. 

I  am  much  interested  in  the  hypothesis  that  the 
appendix  may  be  the  cause  of  right-sided  pyelitis. 
When  one  bears  in  mind  the  great  frequence  of 
chronic  appendicitis  in  women  (generally  not  so 
marked  as  to  cause  noticeable  signs  or  symptoms) , 
it  is  easy  to  suspect  this  structure.  It  may  be  in 
very  close  relationship  with  the  ureter,  and  infection 
might  pass  directly  through  the  peritoneum  or  sub- 
peritoneally  through  the  lymphatics.  In  most  of 
the  cases  of  pyelitis  which  I  have  seen,  no  evidence 
of  appendiceal  trouble  could  be  determined. 

Dr.  Ries  has  referred  to  the  subsidence  of  an 
acute  pyelitis  after  removal  of  the  appendix.  This 
does  not  prove  emything.  Occasionally  an  acute 
pyelitis  will  subside  very  rapidly  without  any  sur- 
gery or  local  treatment. 

I  have  several  patients  with  chronic  pyelitis  from 
whom  I  have  removed  the  diseased  appendix  as  well 
as  the  diseased  genitalia  and  the  pyelitis  continues, 
though  all  the  best  varieties  of  treatment  have  been 
carried  out. 

Vaccine  treatment  has  been  of  value,  in  my  ex- 
perience, especially  in  early  cases  of  pure  colon  in- 
fection, but  I  doubt  if  it  has  been  more  efficacious 
than  mere  hygienic  treatment.  In  old  chronic  cases, 
especially  those  associated  with  an  enlarged  renal 
pelvis,  and  in  those  cases  in  which  there  is  a  mixed 
infection,  I  have  found  vaccine  treatment  most  un- 
satisfactory. 

With  regard  to  lavage  of  the  ureters  and  renal 
pelvis  with  antiseptics,  I  agree  with  Dr.  Kolischer 
thai  it  is  a  futile  method,  and  one  which  is  apt  to 
do  harm.  We  have  abandoned  this  procedure  in 
treating  the  infected  uterine  cavities  as  well  as  other 
cavities  which  are  more  easily  accessible  than  the 
ureter.  The  temporary  trickling  of  an  antiseptic 
stream  can  have  no  germicidal  effect  whatever.  It  is 
diluted  by  the  urine  which  is  passed,  and  soon  es- 
capes into  the  bladder.  It  cannot  penetrate  the  infect- 
ed tissues  of  the  mucosa.  The  only  possible  value  to 
be  obtained  from  irrigation  of  the  ureters  is  in  those 
cases  where  there  is  some  blocking  from  fibrin  or 
cast-off  cells  causing  distress  to  the  patient  by  in- 
terfering with  free  escape  of  urine  into  the  blad- 
der. I  have  relieved  a  patient  in  this  manner.  This 
complication  is  not  very  common  in  ordinary  pye- 
litis cases,  and  lavage  is  therefore  rarely  called  for. 

182 


Even  in  the  hands  of  the  most  expert,  the  passage 
of  the  ureteral  catheter  may  cause  abrasion  of 
the  mucosa,  with  consequent  danger  of  extension  of 
infection.  Sometimes,  even  the  ureter  may  be  per- 
forated. I  saw  a  case  in  which  this  accident  oc- 
curred in  the  hands  of  one  of  the  most  expert  urolo- 
gists m  America.  When  he  injected  coUargol  it 
passed  not  into  the  renal  pelvis  but  through  the  wall 
of  the  ureter  into  the  periureteric  tissue.  Leakage 
of  urine  followed,  and  it  was  necessary  to  perform 
lumbar  nephrectomy  to  save  the  patient's  life. 

Dr.  Clifford  G.  Grulee  (closing  the  dis- 
cussion on  his  part)  :  I  purposely  did  not  dwell 
on  the  subject  of  etiology  or  path  of  infection  or 
treatment,  because  I  had  thought  over  the  thing 
pretty  thoroughly  for  some  time  and  had  not  come 
to  any  definite  conclusion  about  these  points.  There 
are  two  or  three  things  I  will  say  in  this  regard, 
however.  Before  I  prepared  the  paper  for  this 
evening,  I  looked  over  my  cases  of  the  last  three 
years  at  the  Presbyterian  Hospital  and  found 
eighteen,  of  which  four  were  in  boys.  Of  the 
eighteen,  three  died — all  girls. 

In  answer  to  the  statement  of  Dr.  Brennemann 
that  practically  all  deaths  were  due  to  septic  infec- 
tions of  the  kidney,  I  will  relate  one  case  which 
went  to  autopsy,  and  which  Dr.  Kretschmer  saw. 
This  little  girl  was  in  excellent  nutrition;  developed 
a  pyelocystitis  while  in  the  hospital,  and  died  in  an 
acute  septic  condition.  Autopsy  showed  only  a 
slight  inflammation  of  the  pelvis  of  the  kidney, 
ureter  and  bladder,  but  the  liver  resembled  a  mold 
of  butter.  The  toxicity  had  been  so  severe  that  it 
produced  this  marked  fatty  degeneration  of  the 
hver.  So  that  I  do  not  think  we  can  regard  the 
condition  as  only  an  infection  of  the  kidney,  when 
the  result  is  fatal.  There  was  no  other  focus  of 
infection  found  in  this  case,  and  it  seemed  that  the 
infection  of  the  pelvis,  ureter  and  bladder  was  to 
blame  for  this  condition. 

As  to  the  route  of  infection:  I  have  thought  a 
good  deal  about  this,  and  ihe  first  thing  I  thought 
of,  like  many  others,  was  the  hematogenous  theory, 
so  in  seven  or  eight  of  these  children  we  did  blood 
cultures.  In  only  one  case  were  we  able  to  get  a 
positive  culture  of  a  colon  bacillus,  and  that  case 
was  running  a  distinctly  typhoid  course.  Of  course, 
we  know  that  the  blood  has  a  decided  bactericidal 
effect  on  the  colon  bacillus,  and  that  is  not  a  definite 
argument  against  the  colon  bacillus  acting  from  a 
hematogenous  source. 

As  regards  the  question  of  ascending  infection, 
contrary  to  Dr.  Brennemann's  experience,  it  has 
seemed  to  me  that  there  was  no  danger  from  cathe- 
terization of  these  children.  It  has  been  a  routine 
practice  of  ours  to  make  cultures  and  get  the  colon 
bacillus.  In  an  effort  to  find  out  whether  the  colon 
bacillus  was  present  in  a  location  where  it  might 
invade  the  bladder  we  made  routine  examinations 
throughout   the   ward   at   one   time   to   find   if   the 

18.3 


colon  bacillus  was  about  the  opening  of  the  urethra, 
and  in  every  instance  in  these  girl  babies  we  fouad 
it.  It  seems  to  me  that  that  is  an  argument  rather 
against  than  for  ascending  infection,  because  if  we 
can  always  get  a  colon  bacillus  in  that  region,  it 
would  mean  that  it  would  take  a  special  colon 
bacillus  to  produce  the  disease. 

As  to  the  lymphogenous  route,  this  much  can  be 
said:  It  is  not  usually  taken  into  consideration  that 
the  contents  of  the  bowel  are  truly  outside  the  body, 
and  that  until  there  is  some  absorption  from  that 
bowel,  the  content  of  the  bowel  is  not  within  the 
body.  A  colon  bacillus  may  penetrate  a  bowel, 
it  seems  to  me,  if  there  is  some  disturbance  of  con- 
tinuity of  the  mucous  membrane  of  that  bowel.  So 
I  do  not  think  it  is  outside  the  realm  of  possi- 
bility for  the  colon  bacillus  to  penetrate  a  bowel 
which  might  to  all  intents  and  purposes,  be  normal. 

I  have  had  the  distinct  impression  that  many  of 
the  cases  of  colon  bacillus  pyelocystitis  have  occur- 
red in  what  we  term  exudative  diathesis,  a  term 
which  is  probably  not  well  known  to  many  of  you 
here,  but  it  is  a  condition  where  there  is  a  distinct 
tendency  to  a  desquamation  of  the  epithelial  cells 
from  the  mucous  surfaces  of  the  body.  This  can 
be  definitely  proven  in  a  perfectly  normal  child  who 
shows  a  cradle-cap.  If  you  examine  the  urine,  you 
will  find  a  very  marked  increase  of  epithelial  cells. 
It  may  not  be  confined  to  such  surfaces  as  those 
of  the  bladder  and  pelvis  of  the  kidney ;  perhaps  the 
mucosa  of  the  intestinal  canal  may  be  so  affected. 

I  have  not  arrived  at  any  definite  conclusion  as 
to  the  route  of  infection  in  these  cases.  However, 
I  think  it  might  be  a  very  plausible  explanation  to 
say  that  it  might  come  through  the  lymphatic  tissues 
from  the  large  bowel. 

As  to  the  question  of  focal  infection,  focal  in- 
fections do  occur  in  young  children,  and  are  some- 
times followed  by  urinary  and  kidney  involvement. 
My  experience  has  shown  that  the  usual  result  of 
these  focal  infections  was  rather  an  acute  hemor- 
rhagic nephritis  than  a  pyelocystitis. 

As  to  the  question  of  how  soon  bacilluria  pro- 
duces symptoms,  I  cannot  answer  that. 

Regarding  the  number  of  pus  cells,  it  has  been 
questioned  whether  that  was  really  of  practical 
value  in  prognosis.  All  I  can  say  about  that  is  that 
we  have  been  making  routine  examinations  of  the 
number  of  pus  cells  in  the  urine  in  these  cases  for 
several  months.  It  has  been  done  by  the  method  I 
described,  which  is  very  simple.  We  have  found 
that  in  practically  every  instance  where  the  tem- 
perature has  gone  up  the  night  before,  in  the  morn- 
ing specimen  of  urine  we  would  find  an  increased 
number  of  pus  cells.  It  may  be  that  plugging  of 
the  ureter  produces  this  rise  in  temperature,  but,  of 
course,  when  the  discharge  of  the  pus  cells  comes, 
they  must  be  there  in  greater  abundance.  I  did 
not  mean  to  make  the  statement  that  the  number 
of  pus  cells  was  any  indication  as  to  the  severity 

184 


of  the  condition,  but  I  do  think  that  the  course  of 
the  disease  may  be  followed  very  well  by  exam- 
ining the  pus  cells  in  the  urine. 

One  thing  more  as  to  treatment:  I  do  not  be- 
lieve that  urotropin  is  the  treatment  par  excellence 
in  this  condition.  I  usually  start  out  for  four  or 
five  days  with  a  distinctly  alkaline  treatment,  and 
later  on  change  to  urotropin. 

I  have  used  autogenous  vaccines  in  a  routine 
manner,  in  an  effort  to  prevent  recurrence  of  infec- 
tion, and  not  to  change  the  course  of  the  acute 
condition.  In  no  instance  have  I  been  able  to 
persuade  myself  that  these  autogenous  vaccines  had 
any  influence  on  the  question  of  recurrence.  I 
thought  so  for  three  or  four  years,  until  reports 
came  in,  and  then  I  was  very  much  chagrinned 
about  statements  that  I  had  made  formerly  regard- 
ing the  vaccine  treatment  of  these  cases. 

Dr.  Emil  RieS:  Dr.  Kolischer  could  have 
gone  further  in  his  remarks  cuid  could  have  pointed 
out  some  more  difficulties  in  the  pyelitis  question. 
I  have  put  before  you  two  possibilities.  One  was 
that  the  colon  bacillus  gets  out  of  the  appendix,  into 
the  lymphatics,  into  the  sheath  of  the  ureter,  into 
the  pelvis  of  the  kidney,  and  makes  trouble  in  the 
pelvis  of  the  kidney.  It  has  not  made  trouble  on 
its  way.  That  is  queer.  On  the  other  hand,  I 
have  said  that  I  have  taken  out  the  appendix  to  pre- 
vent the  colon  bacilli  entering  the  system  through 
minute  lesions  in  the  appendix.  I  did  not  say  how 
they  got  into  the  pelvis  of  the  kidney.  He  could 
have  tackled  me  there.  What  do  we  know  about 
it?  We  kno^v  that  if  the  colon  bacillus  gets  out 
of  the  bowel  into  the  surrounding  connective  tissue 
and  lymphatics,  we  usually  get  inflammation.  Now, 
it  is  not  Hkely  that  the  colon  bacillus  will  go  through 
all  that  tissue  without  making  infection.  On  the 
other  hand,  if  the  colon  bacillus  gets  through  minute 
lesions  of  the  appendix  into  the  blood  stream,  it  can 
live  in  the  blood  stream  without  causing  much 
trouble,  on  account  of  the  bactericidal  power  of 
the  blood,  and  cannot  produce  trouble  until  it  gets 
out  of  the  blood  stream  into  some  other  place,  for 
instance,  the  pelvis  of  the  kidney.  But  why  there? 
I  have  not  explained  that,  and  I  cannot.  Also,  it 
is  queer  that  if  a  connection  between  the  appendix 
and  pelvis  of  the  kidney  is  to  be  established,  it 
should  be  a  hematogenous  connection,  and  not  af- 
fect both  kidneys  equally  frequently.  If  the  colon 
bacillus  getting  out  of  the  lumen  of  the  appendix 
into  the  blood  stream  were  the  cause,  then  there 
should  be  as  much  probability  of  its  getting  into 
the  left  kidney  as  into  the  right.  But  as  a  mat- 
ter of  fact,  it  gets  into  the  right  kidney  much  more 
frequently,  and  that  agrees  much  more  with  the 
theory  of  its  marching  from  the  appendix  along  the 
lymphatics  on  the  right  side. 

I  gave  a  theory,  and  Dr.  Kolischer  is  right  in 
pointing  out  the  weak  points.  On  the  other  hand, 
it  is  entirely  unnecessary  to  point  out  that  a  micro- 

18.5 


organism  may  be  virulent  m  one  locality  and  not  in 
another — for  instance,  in  the  appendix  and  not  in 
the  blood  stream.  It  is,  also,  not  correct  to  state 
that  a  ligneous  phlegmon  caused  by  a  streptococcus 
is  not  associated  with  endocarditis.  In  ligneous 
phlegmon  a  frequent  cause  of  death  is  septic  en- 
docarditis— there  is  no  question  about  that. 

Dr.  Arthur  H.  Curtis  (closing  the  discus- 
sion on  his  part)  :  A  remark  of  Dr.  Grulee's  re- 
minds me  that  I  was  referring  to  the  use  of  vaccines 
in  chronic  cases,  but  not  in  acute  cases.  In  the 
present  state  of  our  knowledge  of  vaccine  therapy 
it  is  doubtful  whether  it  is  advisable  to  use  them  'n 
any  but  chronic  infections. 

Dr.  Herman  L.  Kretschmer  (closing  ^.the 
discussion)  :  Dr.  Kolischer  said  that  before  an  ac- 
curate diagnosis  could  be  made  in  these  cases  of 
cystitis  or  pyelitis  in  children,  an  examination  of  the 
bladder  must  be  made.  I  have  had  occasion  to 
examine  five  children  in  whom  a  diagnosis  of  colon 
cystitis  had  been  made.  Cystoscopic  examination 
showed  the  infection  coming  from  the  kidney  in 
each  instance. 

Those  of  you  who  are  feuniliar  with  the  very 
convincing  anatomical  work  of  Francke,  must  nat- 
urally agree  with  him  that  a  great  many  of  these 
infections  are  lymphogenous  in  their  origin.  Francke 
has  shown  the  lymphatic  connection  between  the 
large  bowel  and  appendix  in  some  instances,  and  the 
capsule  of  the  kidney.  Coupled  with  the  work  of 
Francke  is  that  of  Stahr.  In  this  way  we  have  a 
direct  connection  between  the  large  bowel  and  kid- 
ney. 

We  should  bear  in  mind  that  in  a  great  many 
cases  of  pyelitis  in  children  we  obtain  a  history 
of  previous  or  recent  attacks  of  gastroenteritis;  the 
possibility  of  having  lesions  of  the  bowel  through 
which  the  colon  bacillus  can  wander  up  the  lympha- 
tics, is  to  be  considered;  it  is  easy  to  see  how 
these  children  can  have  colon  pyelitis  following  at- 
tacks of  gastroenteritis,  in  view  of  Francke's  work. 

Asch,  working  along  opposite  lines  in  dogs,  ad- 
ministered opium,  locked  up  the  intestinal  tract  of 
the  dog,  and  in  his  cases  colon  infection  was  demon- 
strated in  the  urine.  All  Asch  did  was  to  open 
up  the  bowel  with  laxatives,  and  the  colon  infection 
disappeared.  That,  I  think,  would  also  be  an  argu- 
ment in  favor  of  the  lymphatic  origin,  based  on 
Francke's  views. 

The  recent  work  done  by  Sakata,  Sweet,  Bauer- 
eisen,  and  others,  also  demonstrates  a  lymphatic 
connection  between  the  bladder  and  pelvis  of  the 
kidney. 

I  was  glad  to  hear  Dr.  Kolischer  make  the  state- 
ment with  reference  to  the  drainage  and  the  effect 
of  passing  a  catheter  draining  these  cases.  In  two 
cases  in  which  the  patient  had  large  quantities  of 
pus  in  the  urine  we  simply  cystoscoped  them  and 
catheterized  them  for  cultures.  Following  this  they 
had  no  more  trouble.      The  pus  disappeared  from 

18G 


the  urine;  in  all  probability,  we  dilated  the  ureter, 
afforded  better  drainage,  and  hence  the  pus  disap- 
peared from  the  urine. 

In  my  opening  paragraphs  I  made  the  statement 
that  I  was  giving  the  results  of  treatment  used.  I 
made  no  claim  for  silver  nitrate.  All  I  can  say  in 
answer  to  Dr.  Webster  is  this,  that  these  patients 
were  treated  at  the  time  the  treatment  was  begun 
they  had  pus  and  colon  bacilli  in  the  urine;  \vhen 
we  finished  (and  those  cases  were  carried  along  far 
enough),  the  urine  was  free  from  pus  and  the  cul- 
tures were  sterile.  Whether  that  was  due  to  the 
silver  nitrate  or  instrumentation,  I  do  not  know. 
I  am  just  giving  you  the  results  of  treatment. 

It  is  very  true  that  some  advocates  of  pelvic 
lavage  treat  their  patients  by  lavage  with  salt  solu- 
tion, boric  acid  and  oxycyanide  of  mercury,  and 
get  just  about  as  good  results  as  anybody  else. 

Dr.  Bacon  said  he  never  saw  a  very  severe  case. 
I  wish  to  mention  one  case,  in  a  pregnant  woman,  in 
which  the  temperature  ranged  from  96°  to   105'. 

I  was  glad  to  hear  Dr.  Bacon  say  he  did  not  be- 
lieve these  patients  should  have  their  uteri  emptied. 
That  is  the  point  I  wished  to  make  in  my  paper.  In 
two  of  the  cases  I  saw  the  patients  consulted  ob- 
stetricians, who  advised  immediate  emptying  of  the 
uterus,  and  both  cases  went  on  to  a  full-term  preg- 
nancy. 

Dr.  Charles  S.  Bacon  :  I  have  seen  pretty 
severe  cases,  but  none  that  needed  any  other  treat- 
ment than  I  referred  to.  I  did  not  mean  that  I 
have  never  seen  any  severe  cases. 


18Y 


SOME  STUDIES  ON  THE  ANATOMY  OF 
THE  RENAL  PELVIS.* 

By  Daniel  N.   Eisendrath,   M.   D.,  Chicago,   111. 

1  his  is  not  a  purely  anatomical  paper,  but  one 
that  has  considerable  clinical  importance.  As  you 
know,  the  operation  of  pyelotomy  is  the  one  of 
choice  today  in  the  removal  of  renal  calculi,  so 
that  we  have  a  great  many  points  to  consider  in 
the  anatomy  of  the  renal  pelvis  which  we  did  not 
have  to  consider  when  the  operation  was  in  its 
infancy.  For  example,  it  has  occurred  to  me,  and 
in  converstaion  with  Dr.  Young,  he  told  me  he 
had  had  a  similar  experience,  that  in  doing  a  pye- 
lotomy I  accidentally  wounded  a  vein  so  severely 
that  the  bleeding  from  it  was  incapable  of  being 
checked  by  suture  or  emything  else,  and  thus  neces- 
sitated nephrectomy.  In  Dr.  Young's  case,  after 
a  good  deal  of  effort,  he  succeeded  in  checking 
the  hemorrhage  from  the  vein. 

At  the  same  time,  the  teaching  has  been  that 
the  reason  why  pyelotomy  through  the  posterior 
aspect  of  the  pelvis  is  the  operation  of  choice  is 
that  there  is  practically  only  one  artery  there,  and 
that  artery  comes  off  from  the  renal  artery,  goes 
directly  to  the  posterior  aspect  of  the  pelvis,  and 
then  goes  into  what  I  call  the  normal  or  high  type 
of  retropelvic  artery — one  which  passes  along  just 
about  at  the  junction  of  the  renal  pelvis  and  of 
the  parenchyma  of  the  kidney,  or  in  other  words,  at 
the  junction  of  the  sinus  proper  and  of  the  renal 
p>elvis.  That  is  the  high  type — the  normal  type. 
But  in  investigating  (and  this  occurred  to  me  clin- 
ically, also),  I  found  that  this  was  by  far  not 
the  only  type  of  renal  artery,  that  one  had  to  look 
out  for  other  forms  of  retropelvic  arteries.  There 
is  what  is  known  as  a  middle  type,  where  the 
retropelvic  artery  comes  off  directly  from  the  renal 
artery  and  then  crosses  the  middle  of  the  posterior 
aspect  of  the  pelvis,  where  one  has  to  be  very 
careful  not  to  injure  it  in  making  an  incision  into 
the  pelvis,  especially  when  you  think  of  its  being 
mixed  up  with  the  fat  and  imbedded  in  the  peri- 
pelvic  fatty  tissue.  Then  there  is  a  third  type, 
known  as  the  low  type.  I  have  given  these  names 
to  these  types.  No  article  has  ever  appeared  on 
this  subject,  so  far  as  I  can  find.  This  low  type 
crosses  just  about  the  junction  of  the  ureter  and 
pelvis,  on  the  posterior  aspect — not  on  the  anterior 
aspect;  but  those  that  come  directly  from  the  renal 
artery  pass  across  the  pelvic  artery  of  the  pelvis. 

[Illustrations  were  shown,  which  were  taken  from 
specimens  in  the  dissecting  room  of  the  University 
of  Illinois,  through  the  kindness  of  Dr.  Rupert, 
who  placed  all  his  specimens  at  the  speaker's  dis- 


*Read  before  the  Chicago  Urological  Society,  April   I3th, 
1916. 


r Reprinted    from    THE   UROT^OGTC   AND    CUTANE- 
OUS REVIEW,   .Tune,    1916.] 


posal,  and  then  a  large  number  through  Dr.  Sprin- 
ger, the  Coroner's  Physician,  and  some  at  the 
Michael    Reese    Hospital    in    the    autopsy    room.] 

The  typical  retropelvic  artery  was  shown  in  the 
first  specimen.  Also  some  of  the  different  types 
of  pelvis.  Sometimes,  instead  of  there  being  a 
middle  pelvic  artery,  we  have  either  the  high  and 
low  combined  or  the  middle  and  the  low.  Some 
of  the  specimens  sho\v'  that. 

Another  illustration  shows  still  more  variations. 
Occasionally  the  retropelvic  artery,  instead  of  com- 
ing off  from  the  renal  artery,  comes  off  directly 
from  the  aorta  as  in  one  of  the  specimens,  which  is 
of  importance.  If  it  tears  off  during  operation, 
and  bleeding  from  the  depth  of  the  aorta  occurs, 
it  is  hard  to  check. 

Another  specimen  shows  a  retropelvic  artery 
coming  off  directly  from  an  accessory  artery — also 
a  very  important  thing,  in  case  it  happens  to  get 
away  from  you   \vhen  operating. 

So  much  for  the  retropelvic  arteries.  I  will 
speak  of  statistics  in  just  a  minute. 

A  third  series  of  illustrations  were  made  from 
abvout  1  38  kidneys,  and  consider  the  question  of 
the  renal  vein.  That  interests  me  especially,  on 
account  of  having  had  a  severe  hemorrhage  in  one 
case.  We  have  found  some  very  interesting  con- 
ditions, as  regards  the  renal  vein,  in  our  dissections. 
At  times  the  principal  renal  vein,  instead  of  pass- 
ing in  front  of  the  pelvis,  will  pass  behind  it,  so 
that  there  will  be  no  renal  veins  in  front  of  the 
pelvis  at  all,  but  the  entire  large  renal  vein  will 
divide  opposite  the  renal  pelvis  into  two  or  three 
branches. 

Another  interesting  point  is  that  the  renal  vein, 
instead  of  being  the  entire  renal  vein  on  the  pos- 
terior aspect,  will  occasionally  divide  into  two 
branches,  the  main  one  going  in  front  and  the 
other,  almost  equal  in  size,  going  behind  it.  This 
mecuis  that  we  have  got  to  get  away  from  our 
feeling  of  safety  in  doing  pyelotomy,  so  far  as  the 
dangers  of  hemorrhage  are  concerned. 

Regarding  frequency,  so  far  as  arteries  are  con- 
cerned, I  found  in  68  kidneys  which  I  dissected 
for  the  arteries,  in  which  work  Dr.  J.  Kahn  as- 
sisted me,  that  the  high  type  occurred  in  82  per 
cent.,  or  56  cases;  the  middle  artery  occurred  in 
6  per  cent.,  or  4  cases;  the  low  type  in  only  1.5 
per  cent.;  middle  and  low  combined  in  4.5  per 
cent. ;  high  and  low  in  3  per  cent. ;  direct  from  the 
aorta,  1 .5  per  cent. ;  from  the  accessory  artery, 
1 .5  per  cent. ;  all  of  the  renal  veins  were  retro- 
pelvic in  6  out  of  the  68  kidneys,  or  over  9  per 
cent.  Just  think  of  how  much  importance  it  is  to 
know  that  one  anatomic  point.  There  has  never 
been  emy  research  on  this  subject  before,  because 
the  operation  of  pyelotomy  is  comparatively  recent. 
The  renal  vein  divided  into  two  main  branches, 
one  of  these  retropelvic,  in  4  cases,  or  6  per  cent. 
One  thing  I  did  not  mention,  namely:     The  retro- 

189 


pelvic  vein  in  one  case  came  directly  from  the  vena 
cava.     So  much  for  the  arteries  and  the  anomalies. 

Thus,  we  are  safe  in  about  82  per  cent,  of  the 
cases  with  the  usual  instructions  the  books  give  us 
in  regard  to  retropelvic  arteries. 

As  regards  the  renal  pelvis,  that  is  of  consider- 
able importance  in  the  surgery  of  stone.  You  may 
have  a  case  in  which  you  think  you  have  searched 
diligently.  You  open  the  main  renal  pelvis,  be- 
cause the  general  teaching  has  been  that  there  is 
what  is  known  as  the  ampullary  type,  and  that 
the  bifid  and  trifid  types  are  extremely  rare,  and 
you  have  looked  at  the  whole  pelvis,  you  think. 
I  was  interested  to  see  what  proportion  of  cases 
would  be  of  the  ampullary  type,  and  what  pro- 
portion of  the  bifid  and  trifid  types.  In  one  case, 
had  I  not  known  of  these  conditions,  I  think  I  would 
have  missed  one  stone. 

In  the  fetus  the  pelvis  is  an  ampullary  affair. 
We  made  a  dissection  of  a  number  of  fetal  kid- 
neys, and  they  were  all  injected  first  with  bismuth 
paste,  and  then  X-rays  taken.  In  the  fetus  the 
kidney  is  a  diffuse  affair.  There  is  comparatively 
little  parenchyma  in  the  fetal  kidney ;  it  is  mostly 
a  pelvis.  (Here  the  speaker  showed  X-ray  pic- 
tures of  the  ampullary  type.)  Normally,  in  the 
ampullary  type,  we  have  a  relatively  large  sac, 
that  you  know  holds  about  4  c.c,  that  gives  off 
a  superior  and  inferior  calyx,  and  then  very  fre- 
quently a  middle  calyx.  Here  are  all  the  different 
types  of  ampullary  pelves    (illustrating). 

Studying  this  further,  we  find,  in  a  few  of  the 
cases  that  the  pelvis  has  this  typical  form,  with 
two  relatively  small  calyces,  and  there  is  no  am- 
pulla itself,  although  the  ureter  divides  almost  im- 
mediately into  two  horns,  so  that  you  can  see 
what  a  search  would  have  to  be  made  for  a  stone 
under  these  conditions,  and  how  much  damage  you 
could  do  if  you  did  not  look  into  all  the  corners. 

I  have  a  very  pretty  picture  of  double  ureter 
and  double  renal  pelvis,  showing  that  they  were 
quite  separate.  I  had  two  cases  like  that  last 
summer,  one  in  which  the  condition  was  pathological 
in  one  half,  and  not  in  the  other. 

I  have  here  some  preparations  that  we  made  by 
injecting  bismuth  paste  into  the  ureter,  filling  up 
the  renal  pelvis. 

These  are  all  ampullary  types  of  pelves,  with 
the  exception  of  this  one  (indicating).  \  ou  can 
see  the  relation  of  the  vessels  on  the  anterior  aspect 
to  the  renal  pelvis.  This  is  just  the  early  stage 
of  a  bifid  pelvis. 

As  regards  the  frequency,  we  examined  1 5  7 
kidneys  with  reference  to  the  types  of  pelves.  1  here 
were  1  38,  or  87.8  per  cent,  of  the  ampullary  type, 
showing  a  large  proportion,  1  6,  of  the  bifid  type, 
which  shows  they  occur  often  enough  to  think  of — 
I  0  per  cent,  of  the  cases.  There  was  a  percentage 
of  2  of  the  trifid  type — 3  cases.     The  only  work 

190 


that  speaks  of  the  frequency  of  the  different  types 
of  pelves  is  one  that  is  quoted  by  Binney,  of  Keui- 
sas  City,  in  a  work  pubhshed  in  1907.  They 
speak  of  the  classical  or  ampullary  occurring  in 
about  30  per  cent.,  but  our  work  is  really  the  first 
one  that  has  put  this  on  a  little  more  accurate 
basis,  namely,  the  occurrence  in  pretty  nearly  88 
per  cent,  of  the  cases,  of  the  ampullary  form; 
1 0  per  cent,  of  the  bifid,  and  2  per  cent,  trifid. 
Even  so  recent  a  work  as  Kelly's — and  there  is 
no  better  work  than  that — does  not  mention  any 
other  type  of  pelvis  but  the  ampullary.  T  his  is 
not  only  of  anatomical  interest,  but  to  those  doing 
kidney  surgery  it  is  a  matter  of  considerable  im- 
portance to  know  the  anomalies  of  the  veins,  and 
also  the  different  types  of  renal  pelvis. 


191 


SURGICAL    TREATMENT    OF    ACUTE 
EPIDIDYMITIS.* 

By   Charles   Morgan   McKenna,   B.  S.,   M.   D., 
Chicago,    Illinois. 

There  has  been  much  discussion  regarding  the 
surgical  treatment  of  acute  epididymitis  without  ajiy 
definite  conclusion.  I  wish  to  submit  this  paper 
and  the  results  of  a  limited  number  of  cases, 
worked  out  at  St.  Joseph's  Hospital.  Just  a  word 
about  the  anatomy  of  the  epididymis  and  its  sur- 
rounding structures.  It  will  be  remembered  that 
the  epididymis  and  testes  are  enclosed  in  the  same 
sheath,  namely;  the  tunica  vaginalis.  The  nerve 
supply  to  these  two  organs  is  the  same,  being  de- 
rived from  the  aortic  and  renal  plexuses.  Upon 
a  close  dissection,  it  will  be  found  that  the  nerve 
endings  are  more  superficial  in  the  testes  than  they 
are  in  the  epididymis.  The  area  covered  by  the 
testes  is  far  greater  than  that  of  the  epididymis. 
Since  these  are  the  anatomical  findings,  we  must 
take  into  consideration  the  pressure  on  the  testicle 
as  well  as  that  of  the  epididymis. 

In  acute  epididymitis,  we  find  the  beginning  of 
a  hydrocele  or  fluid  around  the  testicle.  All  the 
fascias  between  the  skin  and  the  tunica  vaginalis 
are  upon  the  greatest  tension.  The  tension  is 
so  great  that  the  fascias  can  be  heard  to  make  a 
crackling  noise  upon  dividing  them  with  a  scalpel. 
Dr.  G.  Kolischer  and  the  writer  demonstrated  this 
on  a  number  of  cases  two  years  ago.  Hence,  it 
is  not  enough  to  simply  divide  the  fascias  and  open 
and  drain  the  epididymis,  but  it  is  quite  necessary 
to  separate  the  fascias  one  from  the  other,  auid 
especially  separate  the  tunica  vaginalis  from  the 
testicle  proper.  If  the  wound  were  closed  at  this 
stage  of  the  operation,  the  patient  would  be  greatly 
relieved  of  pain,  as  will  be  shown  later  in  this 
paper.  The  question  that  always  arises.  Is  the 
patient  more  likely  to  be  made  impotent  by  open- 
ing the  epididymis  or  not?  I  should  always  an- 
swer in  the  negative.  It  will  be  remembered  from 
the  anatomy  that  the  epididymis  is  nothing  but  a 
canal  or  tube,  made  up  of  transverse  chambers. 
When  the  patient  is  suffering  with  the  above  named 
pathological  condition  and  after  a  careful  dissec- 
tion, the  tube  stands  out  very  clearly  so  that  the 
operator  can  easily  puncture  the  posterior  wall  of 
the  affected  chamber  without  doing  any  injury  to 
the  small  tubules  coming  off  from  the  testicle. 

I  wish  to  mention  here  that  in  operating  a  num- 
ber of  cases  for  short  circuit  of  the  vas  deferens, 
the  lowest  most  part  of  the  epididymis  showed  the 
sem.iniferous  tubules  to  be  closed  and  this  part  of 
the  epididymis   to  be  a   hollow  tube  without   any 


*Read  before  the  Chicago  Urological  Society,  .April   13th, 

1916. 


[Reprinted    from    THE    UROT.OGIC    AND   CUTANE- 
OUS  REVIEW,   June,    1916.1 


192 


spermatozoa;  on  further  examination,  the  tubules 
coming  from  the  testes  were  blocked.  This,  of 
course,  was  due  to  the  infection  at  the  time  of  the 
acute  condition  not  being  reheved  by  operation  and 
nature  had  to  absorb  the  pus  within  the  lumen 
and,  as  a  result,  the  above  condition  exists. 

Since  this  is  the  result,  it  was  my  reasoning  that 
the  patient  would  less  apt  to  be  impotent  if  the 
pus  were  drained  off  before  the  stenosis  could  take 
place,  hence  leaving  the  tubles  and  main  canal 
open  into  the  vas  deferens.  Many  patients  who 
suffer  with  acute  epididymitis,  and  are  treated  in 
a  palliative  manner,  afterwards  are  often  capable 
of  passing  living  spermatozoa.  This,  of  course, 
is  due  to  the  lessened  amount  of  inflammation  in 
the  epididymis  and  the  amount  of  free  pus  in  the 
vas,  which  is  absorbed  by  nature  at  the  time  of  the 
infection.  The  only  good  reason  for  operating  in 
this  class  of  cases  is  due  to  the  excruciating  pain 
that  they  suffer  at  the  time,  and  the  intensity  of 
pain  is  indicative  of  the  amount  of  free  pus  in 
the  epididymis  and  the  amount  of  inflammation 
surrounding  the  testicle. 

The  following  is  the  report  of  eleven  cases  treat- 
ed in  different  ways  for  the  relief  of  pain.  The 
first  four  cases  were  treated  by  cutting. down  on 
the  epididymis  and  putting  a  gutta-percha  drain 
in  the  lumen.  These  four  cases  were  greatly  re- 
lieved of  pain,  but  it  v/as  from  fourteen  to  twenty- 
one  days  before  the  entire  swelling  was  relieved.  In 
four  cases,  the  epididymis  was  exposed  by  careful 
dissection  and  the  different  fascias  divided  one 
from  the  other  and  the  epididymis  drained.  In 
those  cases,  the  patients  were  entirely  free  from 
pain  and  the  wound  healed  and  the  swelling  dis- 
appeared within  eight  days.  In  two  cases  the 
dissection  was  made  complete  and  the  fascias  sep- 
arated from  each  other,  and  the  epididymis  was  not 
punctured  for  two  days.  Both  cases  had  imme- 
diate relief  from  the  general  pain,  but  complained 
of  a  sharp  toothache-like  pain  in  the  testes.  In 
the  last  case  the  incision  was  made  on  the  opposite 
side,  allowing  the  free  fluid  to  escape  from  the 
tunica  vaginalis.  In  this  case,  the  patient  was 
greatly  relieved  of  pain,  but  not  entirely  so.  Two 
days  later  with  a  local  anesthetic  the  epididymis 
was  opened  and  drained  and  the  patient  entirely 
relieved  of  pain. 

It  may  be  well  to  mention  here  that  doing  what 
is  commonly  known  as  a  blind  stab  operation  is 
not  at  all  to  be  recomended,  because  it  is  quite 
difficult  to  do  this  operation  and  be  sure  to  separate 
the  posterior  wall  of  the  epididymis  without  plung- 
ing the  knife  into  the  tubules  coming  off  from  the 
testicle  on  the  opposite  side.  To  make  a  blind 
stab,  even  though  the  patient  does  get  relief  is 
not  satisfactory. 

Conclusion.  Surgical  procedure  Is  only  neces- 
sary when  the  patient  is  suffering  excruciating  pain. 
When  this  procedure  is  carried  out,  it  is  quite  neces- 

19.3 


sary  to  divide  the  fascias  so  as  to  free  the  tension 
from  the  testicle  as  well  as  the  epididymis.  Patients 
are  less  apt  to  be  impotent  if  the  posterior  wall 
is  divided  carefully  and  the  pus  drained  off  than  if  it 
is  left  to  nature  to  absorb.  A  blind  stab  operation  is 
that  of  a  faker  and  should  not  be  considered.  It 
is  not  enough  to  expose  the  epididymis  and  drain 
it,  but  all  the  fascias  should  be  free. 

It  is  not  necessary  to  split  the  entire  epididymis, 
but  only  the  infected  chamber,  which  stands  out 
clearly. 

25     E.    Washington    St. 


194 


NOTES  ON   URETERITIS.* 

By   Harry  Kraus,   M.   D.,  Chicago,   111. 

Inflammation  of  the  ureters,  although  of  great 
clinicail  and  diagnostic  importance,  is  rather  scantily 
treated  of  in  the  literature.  This  is  partially  due 
to  the  fact  that  this  condition  as  a  rule  is  over- 
shadowed by  the  concomitant  pathology  in  the 
other  urinary  organs,  and  also  to  the  failure  to 
recognize  its  importance  as  a  pathologic  factor.  It 
may  also  be  stated  that  this  condition  is  frequently 
overlooked  because  m  most  mstances  its  presence 
is  revealed  only  by  a  careful  and  more  or  less 
elaborate  diagnosis.  It  may  be  stated  at  the 
outset  that  ureteritis  only  exceptionally  presents  eUi 
independent  clinical  entity.  It  is,  as  a  rule,  either 
dependent  on  general  conditions,  or  caused  by  lo- 
calized infections  of  the  upper  urinary  tract. 

Pregnancy  is  one  of  the  conditions  that  in  a  great 
percentage  of  cases  will  lead  to  disturbance  in  the 
circulation  of  the  ureter  and  in  consequence,  will 
make  it  more  susceptible  to  microbic  invasion.  Ede- 
ma of  the  ureter  is  caused  either  by  pressure  of 
the  enlarged  uterus  in  toto,  or  by  the  pressure  of 
a  fetal  part  against  it. 

That  such  a  pressure  on  the  ureter  exists  is  proven 
by  the  fact  that  ureteral  soundings  in  a  certain  per- 
centage of  pregnant  women  show  an  obstruction  in 
the  abdominal  part  of  this  tube.  This  compression 
of  the  ureter  very  easily  explains  that  the  edema 
will  involve  its  entire  length.  The  existence  of 
this  edema  may  be  recognized  and  proven  by  clin- 
ical evidence.  The  ureteral  vesical  end  shows  signs 
of  edema  and  in  these  cases  there  always  is  a  dim- 
inution of  the  ureteral  flow  and  extension  of  the 
intervals  between  the  urinary  jets.  The  passing  of 
the  ureteral  catheter  beyond  the  point  of  obstruc- 
tion does  not  change  these  phenomena ;  consequently 
it  is  reasonable  to  assume  that  the  edema  extends 
over  the  entire  length  of  the  ureter,  while  the  com- 
mutation of  the  urinary  expulsion  must  be  attributed 
to  the  edema  in  the  renal  pelvis  interfering  with 
the  contractive  energy  of  the  ureter.  That  this  in- 
terference with  the  circulation  often  leads  to  in- 
fection and  mflammation,  becomes  evident  from 
the  fact  that  in  a  certain  percentage  of  these  cases 
the  ureter  concerned  on  palpation  appears  as  a 
thickened  hard  stremd  of  excessive  tenderness.  If 
such  an  inflammation  becomes  very  well  developed 
the  vesical  end  of  the  ureter  appears  in  the  cysto- 
scopic  picture  as  a  prominent  ridge,  which,  if  trans- 
illuminated,  presents  itself  as  a  dark  red  shadow. 
That  the  ureters  quite  often  become  inflamed  as 
the  result  of  an  ascending  infection  conveyed  by 
the  lymphatics,  was  proven  by  animal  experiments 


*Read  before  the  Chicago  Urological  Society,  April   i3th, 
1916. 


[Reprinted    from    THE   UROL,OGIC   AND   CUTANE- 
OUS  REVIEW,   .June,    1916. J 


195 


and  post-mortems  as  quoted  in  the  publications  of 
Baureisen  and  Eisendrath. 

It  is  interesting  to  note  that  on  the  other  hand 
most  of  the  cases  of  ureteritis  become  cHnically 
evident  at  the  lower  part,  and  are  due  to  infections 
coming  down  from  the  parenchyma  and  the  pelvis 
of  the  kidney.  Most  of  these  infections  attack  the 
ureter  at  different  points,  and  the  infected  areas 
are  frequently  separated  by  segments  of  varying 
length  that  are  perfectly  normal.  Only  in  tuber- 
culosis of  the  kidney  the  entire  length  of  the  ureter 
becomes  uniformly  involved,  leading  to  thickening 
and  rigidity  of  the  tube,  always  followed  by  a 
shrinkage  as  to  length.  The  presence  of  a  foreign 
body  in  the  lumen  of  the  ureter  may  lead  to  a 
local  inflammation,  softening  of  a  circumscribed 
area  of  the  wall,  and  eventually  to  sacculation, 
or  to  a  circular  dilation  of  the  ureter  above  the 
seat  of  the  obstruction.  Those  latter  conditions 
can  be  exactly  diagnosed  by  the  injection  of  con- 
trast fluid,  and  the  subsequent  taking  of  an  X-ray 
picture.  The  development  of  a  tumor  in  the  kid- 
ney invariably  leads  to  circulatory  disturbances 
in  the  ureteral  wall  becoming  apparent  to  the  ob- 
server by  changes  around  the  vesical  orifice  of 
the  ureter. 

Obstructions  in  the  parietal  part  of  the  ureter, 
as,  for  instcmce,  produced  by  prostatic  hypertrophy, 
may  also  lead  to  edema  of  the  lowest  part  of  one 
or  both  of  the  ureters,  and  if  prostatitis  or  cystitis 
sets  in,  this  edematous  part  of  the  ureter  becomes  in- 
volved in  this  inflammation,  and  the  ureteral  mucosa 
prolapses,  thus  giving  these  openings  a  pouting 
and  discolored  appearance. 


196 


TRANSACTIONS 
Chicago  Urological  Society. 

The  regular  meeting  of  the  Chicago  Urological 
Society  was  held  April  13,  1916,  with  Dr.  Gustav 
Kohscher  in  the  Chair. 

1  he  Society  was  called  to  order  at  8:30  P.  M. 

"Pathological  Conditions  of  the  Epididymis," 
by  Dr.  C.  M.  McKenna.  (June  issue  this  Jour- 
nal.) 

Discussion. 

Dr.  V.  D.  Lespinasse:  The  surgery  of  the 
epididymis,  particularly  in  acute  infections,  is  one 
that  has  come  up  very  recently,  and  is  one  that 
should  receive  careful  consideration.  Surgery  of 
the  epididymis  should  be  performed  relatively  more 
often  than  it  is.  The  first  dictum  was  that  it 
should  be  done  only  to  relieve  pain,  that  it  should 
be  reserved  for  those  cases  where  the  patient  com- 
plained of  excessive  pain,  which  was  not  relieved 
by  rest  and  elevation.  This,  I  think,  should  be 
extended  a  little  bit,  that  is,  to  forestall  some  of 
the  later  complications. 

It  is  a  question  in  my  mind  as  to  whether  opening 
the  capsule  of  the  epididymis  is  a  good  thing  or  not 
for  the  relief  of  occlusion  of  the  tube.  Experi- 
mentally, if  you  cut  the  capsule  of  the  epididymis 
when  it  is  acutely  inflamed,  the  tubules  bulge. 

When  you  think  seriously  on  this  subject,  there 
are  just  two  things  that  really  require  relief:  (I) 
Pain,  and  (2)  the  possibility  of  closing  up  the 
epididym.is  tubule.  If  the  inflammatory  condition 
does  not  close  the  epididymis  tubule,  it  has  not 
done  any  permanent  damage,  so  if  the  operation 
does  not  actually  lessen  the  number  of  occlusions, 
it  has  failed.  That  is  hard  to  determine.  The 
percentage  of  occlusions  is  uncertain.  The  only  real 
statistics  that  we  have  are  the  old  ones  that  were 
obtained  from  some  reports  of  work  done  in  the 
German  army,  and  they  say  that  forty  per  cent, 
of  double  epididymitis  have  occlusions,  and  twen- 
ty-five per  cent,  of  singles  have  occlusions.  I 
think  it  was  \oung,  of  Boston,  who  had  six  or 
seven  cases  operated  upon,  and  there  were  no  oc- 
clusions. I  have  no  statistics  to  offer  from  my 
own  work.  I  never  operated  on  a  double  acute 
epididymitis,  and  so  far  as  the  singles  are  con- 
cerned, I  have  not  followed  them  and  I  do  not 
know  whether  any  were  occluded  or  not.  But 
this  I  do  know,  that  the  capsule,  when  it  is  cut, 
is  replaced  by  another  capsule  of  scar  tissue,  and 
is  rather  dense  and  rather  hard,  and  may  occlude 
or  not.  So  in  operating  I  practice  the  small  punc- 
ture in  each  compartment  of  the  epididymis.  The 
epididymis  is  a  group  of  rooms,  and  the  long  axis 
of  each  compartment  is  transverse  to  the  long  axis 


[Reprinted   from    THE  UROT^OGIC   AND   CUTANE- 
OUS  REVIEW,   .June.    1916.] 

197 


of  the  epididymis.  The  tubules  are  coiled  in  one 
compartment,  and  then  go  through  the  wall  into  the 
next  compartment,  m  a  good  deal  the  way  the  steam- 
pipes  run  from  room  to  room  in  a  buildmg.  So  that 
when  you  operate  and  have  the  epididymis  exposed, 
notice  the  compartments  that  are  infected,  ^'ou  can 
tell  them  very  easily.  Make  a  little  incision  through 
the  capsule  very  carefully.  The  capsule  is  hard, 
thick,  and  you  must  go  through  very  carefully. 
When  you  get  through,  just  put  a  director  in  and 
free  it.  In  that  way  you  make  a  minimum  wound 
in  the  capsule.  You  have  a  minimum  amount  of 
scarring,  and  if  you  are  careful  you  will  not  cut  any 
of  the  tubules.  That  relieves  pain,  and  probably 
lessens  the  chance  of  occlusion.  If  you  make  large 
incisions,  I  think  that  the  risk  of  occlusion  is  likely 
to  be  increased.  As  I  see  it,  the  whole  matter 
is  one  of  surgical  judgment  and  careful  technic. 

As  Dr.  McKenna  said,  the  blind  stabs — that 
is,  holding  the  testicle  and  just  stabbing  in — do 
relieve  pain,  but  it  is  absolutely  impossible  to  say 
how  deeply  you  go  in  and  what  structures  you 
destroy,  and  if  you  go  deeply  enough  you  are  sure 
to  cut  the  tubule,  and  the  chances  are  that  it  will 
become  occluded.  There  is  less  chance  of  occlusion 
low  down. 

The  function  of  the  epididymis  is  more  than  that 
of  a  conducting  tube.  It  has  a  definite  function. 
It  has  a  definite  secretion.  It  is  a  thin,  rather 
viscid,  glycerine-like  secretion.  It  can  be  seen 
very  well  if  you  ligate  the  epididymis  at  the  upper 
portion,  just  below  the  exit  of  the  tubes  from  the 
testicle;  then  let  the  animal  go  for  a  little  while, 
and,  if  possible,  arrange  to  have  the  female  animal 
there,  let  them  have  intercourse,  so  that  all  the 
spermatozoa  are  cleaned  out  below  the  ligature; 
later  on  ligate  the  vas  or  the  epididymis,  leaving 
a  portion  entirely  occluded.  That  portion  will 
enlarge  and  fill  up  with  this  viscid,  white  secretion. 
This  seems  to  have  some  function  with  regard  to 
the  nutrition  and  development  of  the  spermatozoa, 
and  that,  of  course,  is  practically  never  interfered 
with  to  an  extent  that  amounts  to  anything,  except 
from  the  occlusion.  The  only  place  where  that 
comes  into  play  is  in  the  operations  for  relief  of 
occlusion  where  the  anastomosis  is  made  high  up, 
and  there  the  sperm  has  remained  motionless,  and 
never  become  motile.  So,  as  Dr.  McKenna  said, 
the  point  of  the  epididymis  to  use  for  the  anasto- 
mosis is  the  lowest  possible  point  above  the  occlu- 
sion, and  you  can  usually  tell  that  by  simple  in- 
spection of  the  epididymis. 

Dr.  J.  S.  ElSENSTAEDT:  My  experience  in 
the  operative  treatment  of  epididymis  is  very  slight. 
I  'have  operated  probably  four  or  five  cases.  I 
really  wish  more  to  ask  questions  than  to  tell  any- 
thing. The  whole  point  in  regard  to  the  surgical 
treatment,  it  seems  to  me,  is  whether  the  likelihood 
of  subsequent  sterility  is  greater  following  operation 
than  without  it,  and  until  we  have  statistics  show- 

198 


ing  this,  I  believe  that  a  person  can  do  very  well 
without  the  surgical  procedure.  For  the  simple 
relief  of  pain,  I  think  the  cases  are  very,  very 
far  apart  where  one  does  not  control  the  pain  by 
palliative  measures. 

Secondly,  many  of  these  epididymes  do  not  at 
any  time  in  their  career  contain  an  appreciable 
amount  of  pus.  Very  often  it  is  merely  a  serous 
exudate.     It  may  be  turbid,  of  course. 

Dr.  McKenna  stated  that  after  palliative  treat- 
ment he  IS  no  more  sure  of  the  percentage  of  cases 
in  which  living  spermatozoa  are  found.  That  sim- 
ply is  a  repetition  of  the  remark  that  the  prime  ques- 
tion is  whether  we  are  likely  to  have  fewer  cases  of 
sterility   following  operation  than  without  it. 

Dr.  Irvin  S.  Koll:  I  should  like  to  ask 
Dr.  McKenna  euid  those  who  have  done  a  num- 
ber of  these  operations  how  frequently  they  have 
had  recurrences  following  the  operation?  I  have 
had  several.  I  don't  know  whether  it  is  my  fault 
in  technic  or  is  liable  to  happen  to  emyone.  I  do 
believe  that  operation  gives  some  excellent  results, 
so  far  as  the  pain  is  concerned,  and  have  seen  a 
number  of  cases  in  which  the  most  protracted  pal- 
liative measures  were  of  no  avail. 

Then,  another  indication  I  don't  believe  the 
Doctor  mentioned  is  in  cases  of  recurrent  epididy- 
mitis of  gonorrheal  origin,  that  I  feel  should  be 
classified  in  the  indications  for  the  operation. 

Dr.  McKenna,  closing  the  discussion:  I 
think  the  remarks  of  Dr.  Lespinasse  answer  Dr. 
Koll's  and  Dr.  Eisenstaedt's  question  very  well. 
He  said  the  need  to  see  which  chamber  was  in- 
fected is  one  of  the  most  important  points.  The 
scar  tissue  will  be  much  less  from  an  incision  than 
if  the;  pus  is  left  to  be  absorbed  by  nature.  Dr. 
Eisenstaedt  asked  if  I  found  pus  there  often.  It 
is  a  common  thing  to  find  pus,  a  drop  or  two,  when 
the  pain  is  excruciating. 

As  to  the  question  of  recurrence  asked  by  Dr. 
Koll,  I  have  never  had  a  case  recur  since  I  have 
done  an  open  operation  and  exposed  the  entire  epi- 
didymis. I  have  had  recurrences  when  I  used 
the  old  method  of  going  in  and  making  an  incision 
through  a  number  of  chambers,  regardless  of  which 
ones  were  infected.  If  the  incision  in  the  posterior 
wall  is  small  amd  the  drain  carefully  inserted,  it 
will  be  a  rare  thing  to  have  a  recurrence. 
^  ^  ^ 

"Some  Studies  on  the  Anatomy  of  the  Renal 
Pelvis,"  by  D.  N.  Eisendrath,  M.  D.  (June  issue 
this  Journal.) 

Discussion. 

Dr.  Gustav  Kolischer:  Some  of  the  facts 
brought  out  by  Dr.  Eisendrath  are  very  interesting. 
I  see  their  value  more  in  a  clinical  way.  The 
number  of  such  abnormalities  is  surprising.  The 
question  is  how  to  protect  ourselves  and  the  pa- 
tients against  such  mistakes  as  may  occur  from  not 

199 


discovering  the  existence  of  such  abnormalities.  I 
feel  this  way  about  it.  I  firmly  believe  that  pyelot- 
omy  is  the  operation  of  choice.  But  we  must  keep 
in  mind  that  in  the  normal  kidney  in  the  adult 
there  is  no  such  thing  as  a  lumen  or  cavity  of  the 
renal  pelvis,  consequently  every  time  we  have  to 
operate  on  a  renal  pelvis,  we  have  to  deal  with 
an  abnormal  pelvis,  which,  of  course,  puts  all  the 
normal  insertions  of  the  ureter  and  blood  vessels 
out  of  condition.  What  we  have  to  do  is  this. 
If  we  want  to  operate  on  a  pelvis  at  all,  the  first 
demand  is  an  absolutely  free  and  clean  exposure. 
In  this  way  we  are  kept  from  breaking  into  a  blood 
vessel.  Second,  we  have  to  make  absolutely  sure 
where  the  veins  are,  and  how  many.  It  is  rather 
easy  to  find  the  artery  first  by  palpating,  and,  sec- 
ond, after  delivery  the  artery  will  always  appear 
as  a  very  thin,  white  band.  But  it  is  easy  to  mis- 
take a  dilated  vein,  especially  if  bifurcated,  or  to 
mistake  one  of  the  ramifications  in  the  pelvis  of 
the  kidney  for  adhesions.  In  order  to  be  sure  about 
that  we  should  never  incise  a  pelvis  without  taking 
two  precautions,  first,  to  relax  our  pull  on  the 
kidney  so  as  to  give  a  vein  a  chance  to  refill ; 
second,  we  should  not  incise  the  pelvis  of  the  kid- 
ney without  counter-pressure.  Quite  often  you 
will  see  a  bifurcation ;  the  two  veins  run  over  the 
anterior  surface  of  the  pelvis,  but  if  you  put  your 
finger  behind  it  against  the  wall,  if  you  are  going 
to  incise,  you  separate  these  veins  and  then  you 
can  pull  them  out  of  your  field  of  operation.  This 
counter-pressure  eliminates  mostly  the  danger  of 
cutting  into  a  vein. 

So  far  as  the  removal  of  all  the  concretions  is 
concerned,  there  is  one  golden  rule,  namely,  we 
have  to  remove  as  many  concretions  as  there  have 
been  shown  on  the  X-ray  plate.  We  must  hunt 
for  them.  How  shall  we  do  this  without  destroy- 
ing the  kidney?  Insert  the  little  finger  tip  into  the 
pelvis  and  with  the  other  finger  outside  palpate, 
and  in  this  way  you  can  remove  the  concretions 
which  may  be  high  up  in  the  calices.  If  there  is 
any  adhesion  that  is  suspicious,  it  has  to  be  cut 
between  two  ligatures. 

I  want  to  thank  Dr.  Eisendrath  for  the  exhibi- 
tion of  his  specimens,  because  it  calls  our  attention 
to  the  abnormalities.  It  is,  of  course,  impossible, 
eveo  with  the  most  extensive  statistics,  to  cover  all 
the  possibilities  of  abnormal  conditions,  but  if  we 
know  such  things  exist,  we  can  be  on  the  lookout 
for  them. 

Dr.  Charles  M.  McKenna:  Just  a  ques- 
tion about  the  removal  of  a  stone  from  the  kidney. 
Supposing  there  are  two  stones  in  the  kidney  and 
the  X-ray  shows  one  in  the  pelvis  and  the  other 
in  the  parenchyma.  Where  would  the  incision  be 
made?  I  have  heard  this  question  discussed  often 
without  any  definite  conclusion.  Some  surgeons 
seem  to  think  that  the  best  place  is  in  the  pelvis 
of  the  kidney  and  the  removal  of  the  stone  from 

200 


below.  But  if  this  is  done,  I  think  it  is  necessary 
that  the  suture  be  placed  above  the  upper  margin 
of  the  incision.  1  his,  I  am  afraid,  might  leave 
space  for  a  hematoma  to  form,  and  the  needle  itself 
going  through  the  body  of  the  kidney  also  causes 
a  channel  for  hemorrhage,  whereas  if  the  incision 
is  made  through  the  parenchyma  and  the  suture  put 
through  just  above  the  pelvis  where  the  kidney  ma- 
terial is  very  narrow,  I  think  the  danger  for  hemor- 
rhage is  much  less.  So  far  as  I  am  concerned,  I 
have  had  excellent  results  by  using  the  latter  method. 
Dr.  Gustav  Kolischer:  I  would  like  to 
answer  Dr.  McKerma's  remarks.  It  all  depends 
on  the  location  of  the  concretion.  If  a  stone  is  lo- 
cated in  an  additional  calyx  of  the  pelvis,  there 
is  no  sense  in  cutting  through  the  parenchyma,  be- 
cause this  necessarily  destroys  the  parenchyma.  If 
a  stone  is  located  in  the  cortex  of  the  kidney,  it 
would  be  foolish  to  go  up  through  the  pelvis  to 
get  the  stone.  It  depends  on  the  location  and  how 
much  the  pelvis  and  calyces  are  dilated.  Those 
are  two  different  propositions. 

Dr.  J.  S.  ElSENSTAEDT:  I  would  like  to  ask 
Dr.  Eisendrath  how  much  help  he  has  derived 
from  pyelography  in  these  cases  of  various  types 
of   renal   pelvis? 

Dr.  Eisendrath  (closing  the  discussion) :  In 
reply  to  Dr.  McKenna's  question,  I  agree  with 
Dr.  Kolischer  that  if  you  have  a  stone  in  a  dilated 
calyx,  and  one  in  the  pelvis  proper,  then  by  all 
means  do  a  pyelotomy,  but  if  you  have,  as  he 
spoke  of,  one  stone  in  the  pelvis  and  one  in  the 
parenchyma,  my  own  practice  has  been  to  make 
two  incisions,  one  right  down  on  the  stone  in  the 
parenchyma,  and  then  the  second  one  through  the 
pelvis,  and  deliver  the  pelvic  one  there.  There  is 
no  rule  about  always  doing  pyelotomy  in  these 
cases.  It  is  safer  to  do  the  way  I  described.  A 
stone  in  the  parenchyma  you  can  often  feel  from 
the  surface,  so  make  a  small  incision  and  deliver  it. 

I  agree  fully  with  Dr.  Kolischer  that  so  long 
as  we  know  that  such  conditions  as  I  have  de- 
scribed exist,  it  is  of  great  importance  to  be  on 
the  lookout  for  them. 

I  had  the  same  experience  with  accessory  polar 
vessels,  and  a  great  many  men  later  thanked  me 
for  having  called  their  attention  to  the  work  Dr. 
David  Straus  and  I  published  four  or  five  years 
ago,  on  the  presence  of  these  polar  vessels,  saying 
it  had  saved  them  from  a  good  deal  of  trouble. 
As  Dr.  Kolischer  states,  I  believe  we  should  al- 
ways be  on  the  alert  for  these  conditions.  We 
can  locate  an  artery  easily  enough,  but  the  trouble 
is  with  the  veins — they  collapse, 

I  was  surprised  myself  when  I.  saw  these  dis- 
sections and  the  anomalies  of  the  principal  renal 
veins  coming  away  from  the  vena  cava  directly 
across  the  posterior  aspect  of  the  pelvis.  I  was 
glad  to  know  such  things  exist. 

Regarding   Dr.    Eisenstaedt's   question,    I    think 

201 


there  is  nothing  superior  to  pyelography  for  identi- 
fying these  various  types  of  pelves.  Braasch  has 
very  well  shown  that  in  his  book. 

"Some  Notes  on  Ureteritis,"  by  Harry  Kraus, 
M.  D.      (June  issue,  this  Journal.) 

Discussion. 

Dr.  D.  N.  EiSENDRATH :  Dr.  Kraus  was 
kind  enough  to  quote  the  work  that  we  have  been 
doing.  It  might  be  of  interest  to  you  to  know  that 
we  have  been  repeating  our  experiments  to  find 
out  if  we  had  jumped  to  conclusions  too  soon, 
or  without  sufficient  grounds,  although  we  had  sub- 
mitted our  evidence  to  very  excellent  pathologists 
before  publishing  the  first  paper,  but  we  have  been 
doing  the  same  kind  of  work  again,  and  it  will 
be  reported  in  June.  We  are  finding  the  same 
thing,  that  without  any  obstruction  in  the  ureter 
microorganisms — at  least,  their  footsteps  in  the 
form  of  infiltrations — and  even  the  organisms  them- 
selves so  far  as  cultures  are  concerned,  will  get 
up  into  the  pelvis  of  the  kidney,  by  ascending 
in  the  wall  of  the  ureter,  without  involving  the 
mucosa  at  all,  or  only  in  a  few  places.  We  have 
in  our  last  series  of  experiments,  taken  the  ureters 
and  not  missed  a  single  section,  all  the  way  up 
from  the  bladder  into  the  kidney  proper.  It  takes 
about  700  sections  for  a  dog.  Each  one  has  to 
be  studied,  and  we  are  more  convinced  than  ever 
that  we  are  on  the  right  track,  and  it  corroborates 
what  Dr.  Kraus  has  brought  out  in  regard  to 
pyelitis  of  pregnancy,  and  not  only  true  of  preg- 
nancy, but  also  of  the  puerperium,  and  of  the 
pyelonephritis  that  occurs  in  children,  and,  for  in- 
stance, in  an  ordinary  cystitis  with  or  without  ob- 
struction, namely,  that  infection  will  go  up  the  wall 
of  the  ureter  and  will  cause  a  ureteritis  there, 
which  will  seldom  or  never  cause  any  symptoms. 

A  statement  was  recently  made  by  Chute,  which 
I  also  observed  clinically,  that  when  you  get  these 
chills  and  fever  in  urinary  infection,  they  are  rare- 
ly, if  ever,  due  to  any  absorption  from  the  bladder 
wall.  They  are  usually  the  result  of  absorption 
from  the  kidney  proper.  Since  doing  this  work  I 
Ccui  easily  understand  how  easy  it  is  for  infection 
to  go  directly  through  the  lymphatics,  up  from  the 
bladder  into  the  ureter,  and  up  along  the  pelvis 
of  the  kidney,  and  into  the  kidney  proper,  as 
Bauereisen  has  shown.  It  may  interest  Dr.  Kraus 
to  know  of  some  work  that  was  done  by  Oehlig- 
ger,  of  Hamburg,  in  demonstrating  by  means  of 
collargol  pictures  that  in  pregnancy  the  right  ure- 
ter is  two  or  three  times  the  size  of  the  left  ureter. 

Here  is  another  point  that  has  not  been  called 
to  our  attention  in  relation  to  ureteritis,  namely,  the 
relation  of  the  broad  ligament  to  the  ureter.  That 
is  something  that  has  been  neelected  up  to  the 
present  time.  Undoubtedly,  infection  in  the  fe- 
male gets  up  into  the  kidney  through  the  lym- 
phatics of  the  broad  ligament  to  those  of  the  ure- 

202 


ter.  Bauereisen  has  said  that  he  believes  many 
cases  of  post-operative  renal  infection  in  women 
are  due  to  this  current.  Sampson  was  the  first  one 
to  show  this  relation  of  the  lymphatics  of  the  ure- 
ter, and  especially  the  periureteral  arterial  supply, 
in  its  relation  to  the  broad  ligament  in  carcinoma, 
and  that  is  something  to  elucidate  by  experiment. 
But  we  must  take  something  for  granted,  by  an- 
alogy, and  that  is  that  undoubtedly  a  good  many 
of  the  infections  will  get  up  into  the  ureter,  going 
through  the  bladder.  You  may  be  surprised.  I 
had  no  idea  until  Dr.  D.  J.  Davis  advised  me 
to  make  a  good  many  sections  of  human  ureters 
in  cases  of  ascending  and  descending  infection. 
You  would  be  surprised,  in  cases  of  descending  in- 
fections of  the  ureter,  as  they  occur  in  tuberculosis, 
that  the  mucous  membrane  in  section  after  section 
is  absolutely  intact,  and  the  main  changes  are  in 
the  submucous  and  muscular  periureteral  coats, 
showing  that  evidently  in  travelling  downwards  the 
infection  does  not  need  to  go  along  the  mucous 
membrane,  but  involves  the  wall  of  the  ureters. 

Dr.  Charles  McKenna:  I  should  infer 
from  Dr.  Kraus's  paper,  that  packing  the  bladder 
is  a  common  way  of  infecting  the  ureter,  that  is 
where  the  bladder  is  infected  before  the  operation. 
When  the  bladder  is  packed  tightly  with  gauze  for 
hemorrhage,  it  is  a  common  thing  to  get  an  in- 
flammation around  the  trigone,  hence  a  ureteritis.  I 
remember  one  case  distinctly,  in  which  the  bladder 
was  packed  for  hemorrhage  and  two  days  later 
the  patient  suffered  an  infection  in  both  kidneys 
and  later  died  of  uremia.  That  was  before  the 
transplantation  of  fat  was  introduced  as  a  means 
of  controlling  hemorrhage  in  the  bladder. 

Dr.  Gustav  Kolischer:  I  would  like  to 
call  attention  to  one  point.  I  am  firmly  convinced  of 
the  importance  of  ureteritis  and  circulatory  disturb- 
ance. I  have  made  a  rule  never  to  believe  in  the 
existence  of  a  surgical  kidney  unless  I  find  changes 
around  the  ureteral  opening  of  this  side.  Every 
time  I  have  broken  this  rule  I  got  my  punishment 
for  it.  Why,  for  instance,  the  development  of  a 
tumor  even  in  the  early  stages  leads  to  pronounced 
circulatory  disturbances  at  the  end  of  the  ureter, 
I  do  not  know.  We  know  that  a  deep-seated 
cancer  of  the  mamma  will  lead  to  circulatory  dis- 
turbances which  are  pronounced  and  can  be  seen 
on  the  surface.  Why  it  is,  I  do  not  know,  but  it  is 
so.  You  will  find  in  almost  all  tumors  of  the 
kidney  decided  circulatory  changes  around  the 
ureters.  The  same  holds  good  in  inflammation  of 
the  pelvis.  I  don't  believe  we  are  in  possession  of 
a  sliding  scale  to  diagnose  by  in  conditions  around 
the  ureteral  opening,  as  to  the  character  of  the 
kidney  lesion.  But  if  there  is  such  disturbance, 
there  is  something  wrong  in  the  kidney.  If  lack- 
ing, the  diagnosis  of  surgical  kidney  is  wrong,  or 
very  doubtful.     Unless  the  diagnosis  can  be  made 

203 


in   any  other  way,   I   don't  think  it  is  wise  to  in- 
terfere surgically. 

That  the  ureteritis  in  tuberculosis  is  very  im- 
portant, in  an  operative  sense,  is  shown  by  the  fact 
that  it  is  quite  often  impossible  to  deliver  a  tuber- 
cular kidney  until  the  ureter  is  severed.  So  it 
shows  that  the  ureter  was  shortened,  which  was 
the  only  obstacle  to  the  delivery  of  the  kidney. 


204 


SEMINAL  VESICULITIS.* 

Bv  Edward  Wm.  White,  M.  D.,  Chicago,  111. 

In  reviewing  the  literature  on  seminal  vesicle 
studies,  it  is  interesting  to  note  the  scarcity  of  ma- 
terial at  our  disposal  and  the  limited  number  of 
men  who  have  contributed.  Seminal  vesicle  studies 
have  only  recently  been  given  the  center  of  the 
stage,  not  however  due  to  a  lack  of  interest,  but 
in  all  probability  to  an  incomplete  knowledge  of 
the  correct  pathology  and  also  the  difficulty  of 
a  rational  surgical  approach.  An  article  on  the 
seminal  vesicles  could  not  be  considered  in  any 
degree  complete  were  such  men  as  Fuller,  Squier, 
Belfield,  Schmidt,  etc.,  omitted.  We  are  in- 
debted to  these  early  observers  for  our  stock  of 
knowledge  on  these  subjects.  Fuller's  operative 
studies  on  the  vesicles  date  back  as  early  as  1901, 
and  the  work  advanced  at  that  time  forms  prac- 
tically the  basis  of  our  present  operative  procedure. 
The  Squier  classification  of  symptomatology  as 
"Pain,  Pus,  and  Rheumatic  groups,"  will  cover 
practically  all  classes  that  have  as  yet  come  to 
our  service.  The  Belfield  studies  and  operations  on 
the  vas  have  certainly  lighted  the  path  for  future 
experimentation  and  have  aided  quite  materially 
our  vesicle  work. 

We  have  encountered  no  little  difficulty  in  ar- 
riving at  a  good  brief  classification  of  sympto- 
matology and  pathology.  The  symptoms  being 
varied  due  to  the  anatomical  proximity  of  the 
vesicle  to  the  bladder,  ureter  and  peritoneum.  The 
classification  primarily  suggested  by  Fuller  and 
Belfield  has   been   quite  satisfactory. 

The  symptomatology  of  seminal  vesiculitis  is  ex- 
ceedingly voluminous.  Many  of  the  symptoms 
simulate  cystitis,  prostatitis,  colliculitis  and  posterior 
urethritis.  The  wide  degree  of  variability  of  symp- 
toms is  due  to  the  fact  that  vesiculitis  in  the  true 
sense  has  no  distinct  entity,  but  is  virtually  asso- 
ciated with  a  prostatitis,  a  colliculitis  or  a  posterior 
urethritis. 

Symptomatology. 

Nervous  Types. — In  a  review  of  our  cases  we 
have  found  that  practically  90  per  cent,  were  high- 
ly neurotic  and  of  long  standing.  I  remember  one 
case  in  particular  whose  nervous  manifestations 
were  so  prominent  that  he  was  of  suicidal  intent, 
completely  unfit  for  work,  and  on  examination  very 
little  pathology  was  revealed,  although  the  vesicles 
were  exquisitely  tender.  We  are  of  the  opinion 
that  the  state  of  nervous  irritability  is  largely  due 
to  the  wear  and  tear  of  persistent  pain.  We  have 
had  a  large  number  of  these  cases  under  observa- 
tion, some  have  been  operated,   others  treated  in 


*Read  before  the  Chicago  Urological  Society,  May,  1916. 


[Reprinted   from    THE   UROLOGIC   AND   CUTANE- 
OUS REVIEAV,  July,  1916.] 

205 


the  usual  conservative  manner;  tKe  results  are  not 
gratifying,  although  we  feel  that  many  are  relieved 
by  the  operative  route,  if  only  from  a  psychological 
viewpoint. 

Bladder  and  Urinary. — If  you  pause  to  con- 
sider the  anatomical  proximity  of  the  vesicles  and 
the  bladder,  as  has  been  demonstrated  by  Fuller, 
the  cause  of  the  bladder  symptoms  will  be  readily 
appreciated.  We  have  seen  in  our  routine  cysto- 
scopic  examination  of  these  cases  a  true  "seminal 
vesiculitis  cystitis"  if  you  please,  in  which  the  mu- 
cosa of  the  bladder  overlying  the  vesicle  and  the 
trigonum  was  hyperemic,  edematous,  or  a  mild 
degree  of  trigonal  cystitis.  A  bladder  so  involved 
could  easily  account  for  such  symptoms  as  irrita- 
bility of  the  vesical  neck,  burning  and  throbbing 
sensations,  frequency,  suprapubic  pressure,  vesical 
tenesmus  and  acute  retention  which  is  so  commonly 
noted.  The  majority  of  cases  have  a  typical  muco- 
purulent discharge  of  a  resistant  character,  which 
is  unrelieved  by  the  ordinary  methods  of  treatment. 

Perineal  and  Testicle. — The  symptoms  refer- 
able to  the  perineum  also  are  an  exceedingly  com- 
mon associate  of  vesiculitis.  Under  this  heading 
pain  in  a  variable  degree  ranging  from  only  slight 
discomfort  to  sensations  of  dragging,  drawing, 
feeling  of  fullness  and  pressure.  In  one  case 
where  the  perineal  symptoms  were  quite  pro- 
nounced, the  patient  had  been  unable  to  assume 
his  natural  stride  or  posture  for  months  due  en- 
tirely to  constant  perineal  disturbances.  Many 
of  the  urethral  symptoms  which  occur  at  the  close 
of  urination  are  referred  to  the  perineum.  The 
testicular  symptoms  will  be  disposed  of  m  brief, 
since  many  of  the  cases  have  had  attacks  of  re- 
current epididymitis,  and  naturally  complain  of 
sensitive  epididymes  and  drawing  pains  along  the 
cord.  Noble  and  Picker  were  among  the  first  to 
arrive  at  the  conclusion  that  recurrent  epididymitis 
was  due  to  disease  of  the  vas  and  ampulla.  In  all 
cases  the  perineal  and  testicular  symptoms  were 
duly  prominent. 

Sexual  Symptoms. — If  you  pause  to  consider 
the  true  functions  of  the  vesicles  you  will  not  be 
surprised  to  find  many  symptoms  of  a  sexual  na- 
ture. In  the  early  stages  of  the  disease,  frequent 
erections  with  an  excess  of  nightly  pollutions  are 
not  uncommon,  also,  as  the  condition  progresses, 
a  gradual  diminution  in  sexual  strength  and  finally 
absolute  loss  of  erections  or  impotency  is  noted. 
Painful  orgasm,  painful  and  incomplete  erections, 
hemospermia,  pyospermia,  etc.,  are  all  common 
findings  in  seminal  vesiculitis. 

In  the  opinion  of  Schmidt,  all  cases  of  blood 
and  pus  in  the  ejaculate,  or  blood  and  pus  fol- 
lowing vesicle  massage,  are  proof  positive  of  a 
vesicle  involvement  and  are  worthy  of  surgical  con- 
sideration. It  is  interesting  to  contemplate  the  im- 
provement sexually  in  these  patients  following  ves- 
icle drain.     Fuller  has  reported  a  number  of  such 

206 


cases  in  which  the  sexual  status  was  practically 
normal  six  months  after  operation  and  our  results 
have  been  similar. 

Abdominal. — The  abdominal  symptoms  are  due 
to  the  peritoneal  investment  and  may  simulate  acute 
appendicitis,  ureteritis,  ureteral  colic  or  stone,  and 
are  due  to  the  close  proximity  to  the  bladder.  Ab- 
scess formations  with  perforations  into  this  viscus 
have  been  reported,  also  rupture  into  the  peritoneal 
cavity  by  way  of  the  recto-vesical  cul-de-sac.  Py- 
emia has  been  known  to  follow  a  septic  phlebitis 
of  the  adjacent  venous  plexuses.  Pelvic  cellulitis 
with  marked  suppuration  is  possible.  Dull  persist- 
ent suprapubic  pain,  constant  pains  in  the  lower 
lateral  quadrants  of  the  abdomen  with  a  chronic 
urethral  discharge  should  always  suggest  vesicle 
trouble.  In  reviewing  our  cases  all  have  had  one 
or  more  abdominal  symptoms. 

Rectal  and  Anal  Symptoms. — Rectal  explora- 
tions will  usually  establish  a  diagnosis  patholog- 
ically classified  and  named  in  the  order  of  com- 
parative frequency,  we  have  seen : 

I  St.  The  acute  catarrhal  type.  The  vesicle 
may  be  soft  and  almost  lost  in  the  folds  of  the 
rectum  or  greatly  distended,  tense  and  exquisitely 
tender. 

2nd.  Fibrous  or  sclerotic  type.  The  vesicles  are 
firm  or  markedly  atonic,  the  pains  being  variable. 

3rd.      Suppurative  type  or   abscess  cavities. 

4th.  Pan-inflammatory  type.  The  prostate 
and  vesicles  are  matted  together  in  one  composite 
mass  of  inflammatory  tissue,  with  hardly  a  vestige 
of  normal  landmarks  remaining.  This  type  is  pro- 
ductive of  pains  that  are  referred  to  the  hypo- 
gastrium,  loins,  anus,  perineum  and  sacro-iliac 
synchondrosis. 

The  sensation  of  warmth,  fullness  and  itching 
about  the  anus  is  often  complained  of  and  is  gen- 
erally prominent  in  any  form  of  vesiculitis.  The 
symptoms  are  due  to  the  association  of  the  vesicle 
and  prostatic  plexus  with  the  sacral  and  lumbar 
nerves.  Cowperitis  and  hemorrhoids  will  frequent- 
ly, however,  produce  similar  symptoms  and  should 
be  ruled  out. 

Rheumatic. — Rheumatic  or  joint  symptoms  are 
very  uncommon  in  our  experience,  however  many 
cases  have  been  reported  by  other  authors.  It  is 
not  difficult  to  understand  from  our  knowledge 
of  the  anatomy  of  the  vesicle  and  an  understand- 
ing of  inflammation  in  organs  of  a  similar  type, 
the  modus  operandi  of  systemic  infection.  The 
seminal  vesicles,  once  invaded  by  pathogenic  or- 
ganisms whether  they  be  gonococcus,  streptococcus, 
staphylococcus  or  colon  bacillus,  soon  enter  upon 
a  chronic  inflammatory  state  due  to  insufficient 
drainage.  The  vesicle  sacs  are  characterized  by 
marked  chronicity  with  an  attenuated  form  of  viru- 
lence, infections  may  be  harbored  for  years,  peri- 
odically expressing  septic  material  into  the  general 
circulation.      The    synovial    membranes    are    areas 

207 


of  choice  predilections  due  to  their  natural  weak- 
ness for  invading  organisms.  Squier  states,  "The 
synovial  fluid  is  lymphocytic  instead  of  leucocytic, 
hence  does  not  offer  a  good  phagocytic  power." 

Indications  for  Operative  Intervention. — In  the 
order  of  comparative  frequency  our  cases  have  been 
attacked,  first  for  the  relief  of  pain,  second,  for 
the  evacuation  of  a  pus  vesical,  and  third,  the  re- 
moval of  hard  indurated  fibrous  vesicles  of  long 
standing  and  productive  of  much  discomfort.  The 
rule  so  forcefully  advocated  by  Schmidt  as,  "No 
undue  haste  need  be  exercised  in  advising  opera- 
tions until  all  palliative  measures  have  been  fully 
exhausted,"  has  been  religiously  followed.  We 
have  had  cases  under  observation  for  years,  char- 
acterized by  recurrent  attacks  of  acute  exacerba- 
tion, which  were  finally  freed  of  all  symptoms  by 
persistent  employment  of  palliative  measures.  Con- 
trary, however,  to  the  foregoing  statement  some  of 
our  cases  of  long  standing  have  failed  utterly  of 
any  material  benefit  by  conservative  methods,  but 
were  absolutely  cured  following  operations.  Ves- 
iculectomy is  certainly  the  operation  of  choice  in 
long  standing  cases  with  sclerotic  vesicles  whereas 
vesiculotomy  and  drainage  has  been  entirely  satis- 
factory in  pus  cases  and  the  acute  catarrhal  forms. 

In  summary  it  has  been  found  that  the  following 
classifications  are  all  surgical  possibilities: 

1  St.  Acute  catarrhal  with  marked  general  and 
urinary  symptoms. 

2nd.  Chronic  fibrous,  sclerotic,  unrelieved  by 
treatment. 

3rd.  Pus  and  blood  after  massage  or  in  the 
ejaculate  which  persists. 

4th.  Sexual  neurasthenia  with  a  progressive 
diminution  of  sexual  strength. 

5th.     Tuberculous  vesicles. 

Vasotomy  has  been  resorted  to  in  selected  cases 
as  a  preliminary  step,  (like  the  suprapubic  drain 
prior  to  a  prostatectomy)  and  the  results  were  only 
temporarily  gratifying,  particularly  in  the  cases 
complicated  by  recurrent  epididymitis. 

1.  M.  E..  age  39,  married,  Bulgarian,  came  under  our 
observation  at  the  Michael  Reese  Hospital,  December  6th, 
1915.  One  attack  of  urethritis  six  weeks  prior  to  exam- 
ination. No  luetic  history.  Present  complaint  started  two 
weeks  after  his  urethral  infection  when  he  developed  an 
acute  severe  epididymitis  and  marked  pain  in  perineum 
and  anus,  with  difficult  urination.  These  symptoms  had 
persisted  up  to  the  date  of  our  examination  with  mcreasing 
severity. 

Examination. — Temperature  102",  pulse  full  and  bound- 
ing; patient  very  septic  in  appearance,  complaining  of 
nausea  and  vomiting  in  addition  to  his  urethral  symptoms. 
Also  acute   retention   which  was  relieved  by   catheter. 

Genitalia. — Profuse  gonorrheal  discharge,  very  sensitive 
and  infiltrated  epididymes,  with  associated  orchitis,  also 
thickened   and  sensitive  vas. 

Per  Rectum. — ^Prostate  enlarged,  irregular  and  painful. 
Vesicles  enormous  in  size,  flucluatmg  and  extremely  sensi- 
tive. 

Culture  following  vesicle  massage  revealed  a  growth  of 
staphylococcus,   and   gonococcus.      White   count,   28,000. 

208 


Treatment. — Vesiculotomy  with  drainage  was  performed 
with  the  evacuation  of  a  large  quantity  of  pus.  Two  days 
following  the  operation  all  symptoms  were  alleviated.  White 
count  15,000,  temperature  99\  no  retention,  and  no  dis- 
comfort. Thirty  days  later  the  patient  left  the  hospital, 
stale  of  general  health  satisfactory  and  perineal  incision 
completely  closed.  The  epididymis  was  still  quite  sensi- 
tive on  firm  palpation.  Sexually  normal  and  a  rapid  gain 
in    health   and    strength. 

2.  C.  M.,  age  45;  married;  American;  has  been  under 
our  observation  a  number  of  years  with  three  or  four  at- 
tacks of  urethritis  dating  back  to  1908.  His  urethral  at- 
tacks were  all  characterized  by  more  or  less  vesicle  irri- 
tability, persistent  discharge,  aching  pain  in  glans  penis. 
His  condition  was  unimproved  by  the  usual  treatment  al- 
though religiously  followed  in  every  detail.  In  June  of 
1910,  a  bilateral  vasotomy  was  performed  with  only  tem- 
porary relief  of  symptoms.  On  examination  January,  1916, 
the  patient  had  gained  fifty  pounds  in  less  than  eight  months 
due  to  inactivity  occasioned  by  his  continual  genital  dis- 
turbances. He  was  extremely  neurotic,  phlegmatic  and 
entirely  unfit  for  any  mental  or  physical  work. 

Rectal  Examination.- — Hard,  indurated  and  exquisitely 
tender  vesicles.  Epididymis,  no  pathologic  change  but 
very  pamful  on  palpation.  The  discharge  following  vesicle 
massage  was  heavily  laden  with  pus  and  blood.  A  vesicu- 
lectomy was  done  in  February,  1916,  and  although  the 
operative  course  was  unusually  protracted,  the  patient  left 
the  hospital  four  weeks  later  greatly  encouraged  over  his 
improvement.  When  seen  April  4th,  practically  all  symp- 
toms had  disappeared.  Sexually  improved  and  attending 
to  his  daily  duties.  The  pain  at  the  meatus  remained 
tenaciously  but  was  finally  relieved  by  caput  applications. 
His  case  was  one  of  much  interest  due  to  the  prolonged, 
drawn-out  treatment,  and  clearly  demonstrated  the  fact 
that  vesiculectomy  is  the  operation  of  choice  in  long-stand- 
ing  and   selected   cases. 

3.  M.  T.,  age  28;  married;  laborer.  Presented  for 
examination  January,  1916.  His  past  history  gave  one 
attack  of  urethritis  six  years  before,  this  being  complicated 
by  epididymitis  and  prostatitis.  He  complained  of  swell- 
ing and  pain  in  left  testicle  of  six  weeks'  standing,  also 
severe,  sharp,  stabbing  pain  during  ejaculation  with  a  bloody 
ejaculate.  The  pain  during  intercourse  would  continue 
from  one  to  two  hours  with  marked  depression  following. 
He  had  not  been  exposed  to  any  recent  infection  but  com- 
plained of  constant  mucopurulent  discharge,  and  constant 
aching  pains   in   the  perineum   and   lumbar   regions. 

Examination.- — Urine  very  cloudy  with  specks  and  shreds. 
Urethral  smear  was  negative  to  gonococci  but  contained  an 
abundance  of  other  bacteria  and  many  pus  cells.  Prostate 
enlarged  and  regular  in  contour,  very  sensitive.  The  vesicles 
were  large  and  atonic;  acutely  painful.  The  culture  fol- 
lowing vesicle  massage  gave  colonies  of  staphylococcus  and 
the  smear  full  of  pus  and  blood.  The  left  epididymis  was 
involved   in   inflammatory   infiltration. 

Treatment. — Seminal  vesiculectomy  was  performed  in  the 
usual  manner  as  described  by  Schmidt  in  a  recent  paper 
and  an  uneventful  post-operative  course  followed.  The 
patient  was  up  and  about  in  twelve  days  after  the  opera- 
tion, and  although  still  complaining  of  many  of  his  former 
symptoms  was  dismissed  in  three  weeks.  When  seen  four 
weeks  later  he  gave  a  favorable  report,  all  pains  had  com- 
pletely disappeared,  sexually  perfectly  normal,  with  a 
marked  improvement  in  general  health.  It  has  been  found 
that  these  cases  do  not  clear  up  immediately  after  the 
operation  but  nature   must  be  given   time   to   adjust   itself. 

4.  C.  C,  age  38;  married;  chauffeur;  examined  No- 
vember 8th,  1916.  He  gave  a  past  history  of  one  attack 
of  urethritis  eighteen  years  ago  complicated  by  left  epididy- 
mitis and  stricture  formation.  Patient  stated  that  he  had 
never  been  entirely  free  from  symptoms  since  first  infec- 
tion. He  complained  of  a  constant  burning  in  the  urethra 
with    discharge,   burning,    throbbing   and   drawing  sensations 

209 


in  perineum,  and  frequency  in  urination.  Sexually  vigorous 
by  complaining;  of  an  aggravation  of  all  symptoms  follow- 
ing any  sexual  act. 

Examinalion. — A  bilateral  inflammatory  infiltration  of 
cord  and  epididymis.  Rectal  exammation  revealed  hard 
and  cord-like  vesicles  which  were  extremely  painful  on 
palpation.  The  smear  following  vesicle  massage  con- 
tained almost  pure  pus  and  blood,  culture  gave  colonies 
of  bacillus  coli.  Urethroscopically,  decided  congestion  of 
posterior  urethra,  a  hypertrophied  and  easily  bleeding 
caput,  very  sensitive. 

C^stoscopicall^. — Congestion  of  vessels  of  base,  slight 
degree  of  trigonal  cystitis  and  unquestionably  congestion  of 
vessels  of   the  mucosa  overlying  the  vesicles. 

Treatment. — Seminal  vesiculotomy  with  drainage  No- 
vember   13,    1916. 

Post-Operative. — In  ten  days  following  the  operation 
was  noted  a  marked  diminution  in  the  intensity  of  all  symp- 
toms. The  drains  were  removed  on  the  fifth  day  and  the 
patient  was  fairly  comfortable.  He  complained,  however, 
of  loss  of  erection.  The  post-operative  course  was  unevent- 
ful and  he  was  dismissed  two  weeks  later  with  perineal  in- 
cision practically  closed.  When  seen  two  months  after- 
ward he  complained  of  absolute  loss  of  erections  and  de- 
sire, also  areas  of  anesthesia  extending  over  the  left  half 
of  the  scrotum  and  localized  parts  in  perineum.  His  gen- 
eral stale  of  health  was  splendid,  no  pain  nor  discomfort 
and  all  former  symptoms  had  entirely  disappeared.  His 
sexual  condition  was  only  slightly  improved  when  seen 
three  months  following  the  operation,  however,  the  areas 
of  anesthesia  had  disappeared.  We  are  of  the  opinion 
that  his  sexual  status  will  return  to  normal  in  time,  since 
regular  caput  applications  have  given  some  slight  improve- 
ment. 

5.  J.  W.,  age  30;  single;  American.  He  gave  a  past 
history  of  prostatitis  in  1903,  and  an  external  urethrotomy 
in  1914,  also  several  attacks  of  urethritis.  He  came  under 
our  observation  complaining  of  extreme  nervousness,  con- 
stant suprapubic  pain,  frequency  of  urination  with  drib- 
bling, sexual  weakness  and  a  complex  of  irritative  symp- 
toms referable  to  the  perineum  and  external  genitalia.  He 
had  been  under  our  care  since  1907  with  varying  degrees 
of  improvement  and  decline,  highly  neurotic  and  un- 
usually sensitive.  The  usual  method  of  treatment  was  con- 
formed to  with  unsatisfactory  results.  In  February,  1913,  a 
bilateral  vasotomy  was  performed  with  only  a  temporary 
alleviation  of  symptoms.  Four  weeks  later  his  condition 
was  exceedingly  unfavorable,  embracing  an  inhibition  of 
sexual  desire,  with  loss  of  erections  and  also  muscular 
spasms  in  the  perineum.  His  attempts  at  intercourse  were 
followed  by  lancinating  pain  and  bloody  ejaculate.  He 
became  totally  unfit  for  mental  or  physical  effort,  a  com- 
plete nervous   breakdown. 

Examination. — Cystoscopically  congestion  and  contraction 
of  the  urinary  surface,  mild  degree  of  trabeculation  with 
severe  trigonal  cystitis.  Genitalia,  negative  as  to  morbidity 
but  unusually  sensitive  to  palpation,  especially  the  epididy- 
mis and  vas. 

Treatment. — Seminal  vesiculotomy  with  drainage  Febru- 
ary, 1915,  and  although  the  post-operative  course  was  pro- 
longed the  results  were  satisfactory.  In  four  months  fol- 
lowing his  dismissal  from  the  hospital  the  irritative  symp- 
toms of  the  perineum,  rectum  and  epididymes  were  prac- 
tically gone,  the  nervous  irritability  was  relieved  and  his 
state  of  health  improved.  When  seen  about  two  months 
ago  he  had  gained  thirty  pounds.  Dr.  Schmidt,  who  ex- 
amined him  cystoscopically  at  the  time,  reported  a  marked 
improvement  in  vesicle  findings  and  a  satisfactory  condi- 
tion per  rectum.  Persistent  rectal  douches  and  Sitz  baths 
had  relieved  the  inflammatory  rectal  findings.  This  case,  in 
all  probability,  was  the  most  difficult  that  we  have  had 
under  our  observation  and  considering  the  magnitude  of 
symptoms   and   pathology   we    feel   satisfied   with   the   results. 

L.  B.,  age  28,  single,  laborer.     Patient  developed  an  at- 

210 


tack  of  acute  retention  during  the  course  of  an  acute 
urethritis.  He  complained  of  deep  perineal  pain  and  ten- 
derness, pain  on  defecation,  aching  pain  in  inguinal  regions 
and  profuse  gonorrheal  discharge.  He  was  very  septic  in 
appearance,  temperature  103°,  pulse  120  and  white  count 
22,000. 

On  examination  per  rectum,  there  was  revealed  a  large 
tumefaction,  bulging  into  the  rectal  space.  Immediate 
seminal  vesicle  drainage  advised.  The  vesicles  were  ex- 
posed in  the  usual  manner  and  could  be  easily  outlined.  A 
large  quantity  of  pus  was  evacuted  from  each  vesicle  and  the 
parts  drained.  All  symptoms  were  greatly  relieved  and 
normal  urination  was  established  within  twenty-four  hours 
following   operation. 

A.  L.,  age  34;  Italian.  Seen  at  Alexian  Brothers  Hos- 
pital. The  patient  gave  a  past  history  of  five  attacks  of 
urethritis  of  which  two  were  complicated  by  epididymitis. 
He  presented  himself  complaining  of  urinary  frequency 
with  great  pain  during  and  after  intercourse,  also  sharp 
stabbing   pain   during   ejaculation. 

Examination. — The  typical  chronic  mucopurulent  dis- 
charge at  meatus  a  case  of  infiltrative  urethritis;  his  urine 
was  turbid  in  all  glasses  and  contained  a  quantity  of  sper- 
matozoa. The  third  glass  following  vesicle  massage  was 
laden  with  pus  and  blood. 

Rectal  palpation  revealed  a  pair  of  dense,  sclerotic  sen- 
sitive vesicles,  irregular  in  outline.  Seminal  vesiculotomy 
was  performed.  The  post-operative  course  was  uneventful, 
and  when  seen  eight  weeks  later  after  his  dismissal,  patient 
reported  intercourse  entirely  satisfactory,  and  no  urinary 
symptoms. 

The  question  naturally  arises  after  hearing  the 
report  of  cases  as  to  when  is  vesiculectomy  indicated 
and  when  should  a  vesiculotomy  be  advised.  In 
our  opinion  the  vesicles  should  be  removed  intact 
in  all  cases  of  multiple  abscesses  with  extensive 
destruction  of  the  tissues.  Secondly,  the  cases  of 
long  standing  with  hard  fibrous  sclerotic  vesicles 
that  are  productive  of  bladder  cheinges.  Thirdly, 
that  class  of  cases  in  which  the  vesicles  and  am- 
pulla, due  to  proximity  to  the  ureter  and  surround- 
ing parts,  are  productive  of  symptoms  referable 
to  these  organs.  While  in  our  opinion,  (and  in 
that  of  others),  it  is  not  advisable  to  remove  the 
vesicles  unless  they  are  sufficiently  pathologic,  yet 
in  selected  caces  of  extreme  nervous  origin  unal- 
tered by  the  usual  methods  of  treatment,  seminal 
vesiculectomy  has   been   entirely   satisfactory. 

Relative  to  seminal  vesiculotomy,  we  have  con- 
sidered all  cases  of  spermatorrhea,  all  cases  of  pus 
and  blood  in  the  ejaculate  and  followmg  vesicle 
massage,  and  the  acute  catarrhal  and  suppurative 
type.  As  yet  no  tuberculous,  cystic  or  calcareous 
cases  have  been  operated  on  by  us.  In  view  of 
the  fact  that  work  on  the  vesicles  is  still  in  a  prim- 
itive stage  and  the  tabulated  results  of  other  ob- 
servers so  scarce,  we  have  had  no  little  difficulty 
in  arriving  at  good  operative  classifications.  The 
majority  of  these  cases  reported  have  been  oper- 
ated within  the  last  year  and  further  observations 
will  certainly  reveal  important  information. 

As  a  closing  remark  I  should  like  to  thank  Dr. 
L.  E.  Schmidt  for  his  kmd  co-operation  and  as- 
sistance in  making  this  report  possible. 


211 


BIBLIOGRAPHY. 

1.  Squier,  Indications  for  Operations  on  the  Seminal 
Vesicles.  Bosion  Medical  and  Surgical  Journal,  1914, 
CL.  XX,  908. 

2.  Squier,  Surgery  of  the  Seminal  Vesicles.  Cleveland 
Medical  Journal.    1913,   XII,  801. 

3.  Smith,  E.  O.,  Anatomy  and  Pathology  of  the  Sem- 
inal Vesicles.  Urologic  AND  Cutaneous  Review,  V. 
22,   February,    1916. 

4.  Hyman  and  Saunders,  A  Clinical  Resume  of  Chronic 
Seminal    Vesiculitis.      New     Yorl(    Medical    Journal,     1913, 

V,  97,  pp.  652-654. 

5.  James  and  Shuman,  Seminal  Vesicle  Calculi  Simulat- 
ing Nephrolithiasis.  Surger}),  C^necolog^  and  Obitelrics, 
XVI,    1913. 

6.  Thomas  and  Pancoast,  Observations  on  the  Path- 
ology, Diagnosis  and  Treatment  of  Seminal  Vesiculitis. 
Annals  of  Surgery,  1914,  V.  60,  p.  313. 

7.  Fuller,  Seminal  Vesiculitis.  Journal  American  Med- 
ical Association,  Nov.  30,  1912,  p.  1901;  Journal  Amer- 
ican Medical  Association,  May  4,  1901,  p.  1901;  Journal 
American  Medical  Association,  Nov.  30,  I9i2,  p.  1951; 
A'en;  York  Medical  Record,  Oct.  30,  1909;  Annals  of 
Surgery,  April,  1905;  A'eiD  York  Medical  Record,  May 
21,  1904;  New  York  Post-Craduate,  Oct.,  1904;  Amer- 
ican  Journal    of    Urology,    December,    1906. 

8.  Belfield,  Irrigation  and  Drainage  of  Seminal  Duct 
and  Vesicle  Through  the  Vas  Deferens.  Surgery,  Gyne- 
cology and   Obstetrics,    1906. 

9.  Cabot,  Some  Suggestions  in  Regard  to  the  Diagnosis 
of  Seminal  Vesiculitis.  Boston  Medical  and  Surgical  Jour- 
nal,   May,    1915, 

10.  Billings,  Archives  of  Internal  Medicine,  April, 
1912;  Journal  American  Medical  Association,  Sept.  13, 
1913. 

11.  Schmidt,  Vesiculectomy  and  Vesiculotomy.  Journal 
American  Medical  Association,  Jan.  15,   1916. 

12.  Plaggemeyer,  Tuberculosis  of  the  Seminal  Duct. 
Journal  Mechigan  State  Medical  Society,    1916,   XV,    118. 

1616   Mailers   Bldg. 


212 


ASPERMATISM.- 

By  V.  D.  Lespinasse,  M.  D..  Chicago.  111. 

Aspermatism  as  defined  by  Roubaud  in  1855 
is  characterized  by  the  failure  of  ejaculation  with 
a  normal  erection  as  against  priapism  and  with 
neither  perversion  or  exaltation  of  the  normal  fac- 
ulties as  against  erothromania. 

Roubaud  reported  one  case  of  his  own  and  de- 
scribes one  case  as  occurring  in  the  practice  of 
Cockburn   of   Venice. 

My  patient  came  to  me  complaining  that  the 
act  of  intercourse  was  never  satisfactorily  finished. 
He  is  married  and  has  never  attempted  intercourse 
with  any  one  but  his  wife  and  has  had  this  trouble 
throughout  his  entire  married  life.  He  has  never 
been  sick,  is  in  perfect  general  health,  an  auto- 
mobile salesman  by  occupation,  has  never  had  any 
venereal  disease.  Examination  shows  a  young  man 
25  years  old  of  normal  nutrition  and  of  a  healthy 
color.  The  external  genitals  are  normal  as  to 
size,  development  and  general  appearance.  Tes- 
ticles are  of  normal  size,  normal  tension  and  both 
hang  in  the  scrotum  as  they  should.  Penis  is 
of  normal  size,  urine  is  clear  and  free  from  al- 
bumen and  sugar.  Rectal  examination  shows  the 
prostate,  vesicles  and  bulb  of  the  urethra  normal. 
Cystoscopic  and  urethroscopic  examinations  reveal 
nothing  pathological.  He  has  normal  sexual  de- 
sire, normal  erections,  normal  penetration  and  nor- 
mal mtercourse  m  every  way  up  to  the  point  of  ejac- 
ulation. No  matter  how  long  or  how  vigorously  the 
act  IS  carried  out  or  what  psychic  aids  are  brought 
into  play,  ejaculation  never  takes  place  and  the  act 
is  concluded  v»'hen  both  he  and  his  wife  are  physi- 
cally exhausted  or  simply  stop.  The  patient  has 
dreams  which  are  accompanied  by  emissions  and 
the  fluid  discharged  contains  prostatic  fluid,  sperm- 
atozoa and  all  the  elements  that  a  normal  man 
would  pass  under  similar  circumstances. 

From  cursory  examination  of  literature  I  find 
two  similar  cases  reported  from  American  literature, 
one  by  H.  C.  Simes  of  New  York,  in  the  A'^.  Y. 
Medical  Journal  in  1895,  and  one  by  W.  H. 
Van  Buren,  Vol.  8,  page  126,  of  the  New  Yorff 
Medical  Journal. 


*Read  before  the  Chicago  Urological  Society,  May,  1916. 


[Reprinted    from    THE    UROLOGIC    AND    CUTAXE- 
OUS   REVIEU',   July,   1916.] 


213 


TRANSACTIONS 
Chicago  Urological  Society. 

The  Annual  Meeting  of  the  Chicago  Urological 
Society  was  held  Thursday  evening.  May  25th,  at 
Hotel  Sherman,  the  President,  Dr.  H.  L.  Kretsch- 
mer,  in  the  chair. 

The  first  item  on  the  program  was  a  paper  by 
Dr.  E.  W.  White,  entitled  "Indications,  Results 
and  Case  Reports  of  Seminal  Vesiculotomy  and 
Seminal  Vesiculectomy."     (July  issue  this  journal.) 

Dr.  Kretschmer  requested  that,  owing  to  the 
large  volume  of  business,  the  discussion  be  limited 
to  four  minutes  each. 

Dr.  L.  W.  Bremerman  :  I  would  like  to  ask 
Dr.  White  a  question.  Although  he  expressed  very 
clearly  the  differentiation  between  those  cases  where 
vesiculectomy  and  vesiculotomy  are  possible,  it  did 
not  appear  clear  to  me  in  which  cases  vesiculectomy 
was  indicated  and  in  which  vesiculotomy  was  indi- 
cated. In  one  group  he  said  that  vesiculectomy 
was  indicated,  and  if  he  would  make  that  point  a 
little  more  definite  I  think  it  would  throw  more 
light  on  the  subject  for  all  of  us. 

Dr.  Robert  H.  Herbst:  I  was  quite  pleased 
to  hear  the  emphasis  which  Dr.  White  placed  on 
the  importance  of  surgical  intervention  in  the  treat- 
ment of  seminal  vesicle  infections.  I  do  not  quite 
agree  with  him  as  to  the  choice  of  operative  pro- 
cedure. I  believe  that  vesiculectomy  is  almost 
never  indicated  in  seminal  vesicle  infections.  1  can 
remember  the  day  when  surgery  directed  to  infec- 
tion of  the  seminal  vesicles  was  extremely  rare,  but 
today  I  think  most  of  us  believe  that  we  should 
interfere  surgically  in  many  of  these  cases.  When 
the  gonococcus  invades  the  male  urethra,  I  believe 
that  about  90  per  cent,  of  cases  become  posterior, 
and  that  in  almost  every  case  the  seminal  vesicles 
become  involved.  When  this  occurs,  I  am  con- 
vinced that  the  chance  for  cure  by  palliative  meas- 
ures or  spontaneous  healing  is  remote.  In  many 
of  these  infections,  especially  of  the  gonococcus 
type,  vasotomy  followed  by  injections  of  the  vesicles 
with  collargol  solution,  has  proved  very  efficacious 
in  my  hands.  There  are  cases  in  which  vesiculot- 
omy is  indicated,  but  I  believe  they  are  in  the 
minority. 

Dr.  V.  D.  Lespinasse  :  I  don't  think  any  of 
us  would  hesitate  to  open  up  the  type  of  vesicle  Dr. 
White  has  described,  for  they  were  acute  cases 
with  acute  inflammatory  symptoms.  We  all  see 
another  type  of  case,  however,  and  that  is  the  type 
of  case  that  gives  me  the  greatest  concern  as  to 
operative  treatment,  for  instance,  the  man  who  has 
a  slightly  thickened  vesicle  and  who  has  a  discharge, 
possibly  a  little  pus  in  his  ejaculate,  but  you  are 
not  sure  whether  it  comes  from  the  vesicle  or  the 


[Reprinted    from    THE    l-Uol.or.lC    AND    CUTANE- 
OUS REVIEW,   July,   1916.] 

214 


prostate.  He  may  have  a  prostatitis  as  well  as  a 
vesiculitis.  That  is  the  type  of  case  that  makes 
it  hard  for  me  to  decide  whether  to  operate  or  not, 
and  which  operation  to  perform.  I  have  done  a 
vasotomy  on  this  type  of  case;  sometimes  success- 
fully, but  my  results  have  not  been  particularly 
brilliant.  Very  few  of  my  cases  with  chronic 
vesiculitis  will  submit  to  the  three  or  four  weeks' 
hospital  stay  for  necessary  vesiculectomy.  1  hey 
will  accept  the  one  day  which  vasotomy  entails. 
In  these  cases  I  make  an  X-ray  after  the  vesicle  is 
injected  and  also  determine  if  the  fluid  comes 
through  into  the  urethra  quickly  or  slowly.  If  it 
comes  through  very  rapidly  I  interpret  it  to  mean 
that  the  vesicle  is  small.  Then,  backed  up  by  the 
picture,  if  it  shows  a  few  convolutions  I  interpret  it 
to  mean  that  later  on  this  vesicle  may  be  a  case  for 
vesiculectomy,  as  the  vesicular  walls  are  infiltrated. 
When  you  have  cured  your  vesiculitis  have  you 
really  cured  your  patient?  I  think  we  may  cure 
the  vesiculitis  and  have  the  infection  still  present 
in  other  locations.  That  is  a  stumbling  block  to 
me,  and  a  great  disappointment  to  the  patient.  They 
are  operated  for  the  relief  of  the  discharge  and  you 
have  done  a  brilliant  operation — but  the  patient  still 
has  the  discharge  coming  perhaps  from  a  urethral 
folicle  or  the  prostate. 

Dr.  Welfeld:  While  vesiculectomy  is  still 
in  its  infancy,  I  think  operative  procedure  should 
be  indicated  only  in  the  cases  Dr.  White  has  men- 
tioned. I  think  all  cases  of  vesiculitis  should  be 
subjected  to  palliative  treatment  as  much  as  possible. 
Most  patients  of  the  better  element  will  not  submit 
to  operative  treatment  unless  they  absolutely  have 
to.  They  know  from  previous  experiences  that  the 
attacks  will  subside  in  a  short  time  with  possible  re- 
currences in  the  remote  future.  But  the  incon- 
venience of  the  attacks  does  not  compare  with  the 
inconvenience  of  such  an  operation  with  weeks  and 
weeks  of  convalescence. 

Dr.  Charles  McKenna:  I  don't  think  that 
Dr.  White  mentioned  the  question  of  sterility  in 
connection  with  doing  vasotomy.  By  this  I  don't 
mean  that  all  patients  become  sterile  after  vasotomy, 
but  I  do  mean  that  some  patients  are  made  sterile 
after  a  number  of  injections  are  made  into  the  vas. 
I  think  it  is  quite  necessary  that  the  patient  should 
be  made  to  understand  the  possibility  of  sterility 
after  doing  such  an  operation.  I  know  of  two  cases 
that  have  been  made  sterile  by  doing  vasotomy.  It 
stands  to  reason  that  when  the  operator  is  dealing 
with  a  lumen  as  small  as  that  in  the  vas,  he  is  bound 
to  get  organization  from  traumatism  and  blood  clot. 
I  therefore  think  it  is  highly  necessary  that  this 
point  be  taken  into  consideration. 

Dr.  J.  S.  EisenstaedT:  I  think  there  is  an- 
other type  of  seminal  vesiculitis  which  does  not 
come  in  the  classification  by  Fuller  and  Belfield, 
and  that  is  a  type  of  subacute  or  catarrhal  vesicu- 
litis.    I  had  a  case  this  week  which  emphasized  that 

215 


type.  I  had  a  patient  who  complained  of  intense 
pain  in  the  right  testicle  shooting  up  into  the  groin 
to  the  iliac  crest.  There  was  no  temperature.  The 
pains  would  force  him  to  double  up  like  the  pains 
of  appendicitis.  The  patient  is  married  and  has 
not  been  exposed  to  infection  for  six  years.  He 
had  gonorrhea  eight  years  ago.  The  prostate 
showed  nothing  abnormal  to  palpation,  but  the  right 
vesicle  was  tender — not  exquisitely  so,  however.  I 
was  surprised  at  the  amount  of  pressure  which  he 
stood  without  complaining.  After  stripping  the 
vesicle  two  or  three  times  and  putting  argyrol  in, 
the  pains  of  which  the  patient  complained  entirely 
disappeared. 

Another  point  which  I  believe  should  be  em- 
phasized is  the  very  definite  information  which  we 
are  able  to  get  by  cystoscopic  examination.  As 
Dr.  White  so  accurately  described,  the  trigonitis  is 
usually  unilateral,  and  if  not  unilateral  at  least 
very  much  more  marked  over  the  side  where  the 
vesicle  is  affected.  There  are  many  cases  of  vesi- 
culitis without   any   epididymitis. 

Dr.  H.  L.  Kretschmer:  Surgical  treatment 
of  the  seminal  vesicles  has  the  call  of  the  day. 
The  surgical  management  of  these  cases  will  have 
to  be  considered  from  two  standpoints:  first,  indi- 
cations for  operation,  and  second,  the  end  results. 
Cases  in  which  there  is  acute  pus  infection  of  the 
seminal  vesicules  I  think  should  be  opened  and 
drained.  I  recall  two  or  three  such  patients  who 
had  complete  retention :  the  vesicles  were  opened 
and  drained  which  was  followed  by  complete  re- 
lief of  the  symptoms.  I  think  the  chronic  cases 
should  be  selected  with  a  great  deal  of  care  and, 
only  after  non-operative  treatment  has  failed.  I 
have  talked  with  a  number  of  men  who  had  per- 
formed vesiculotomy  and  vesiculectomy  as  to  end 
results,  particularly  as  to  the  sexual  results,  and 
they  all  tell  you  that  one  or  two  of  their  cases  have 
had  a  complete  loss  of  sexual  power.  I  think  this 
is  very  important  and  I  am  going  to  ask  Dr.  White 
to  tell  us  his  results.  I  don't  believe  these  cases 
should  be  operated  upon  just  to  be  operating.  I 
should  like  Dr.  White  to  tell  us  in  how  many  cases 
they  were  able  to  demonstrate  gonococci  in  the 
vesicle,  and  in  their  absence  to  tell  us  what  or- 
ganisms they  found. 

Dr.  HerbsT:  I  feel  that  I  cannot  allow  Dr. 
McKenna's  statement  to  go  unchallenged.  Do  you 
believe  that  every  case  upon  w^iich  you  perform  a 
vasotomy  is  made  sterile? 

Dr.  McKenna:  I  didn't  say  that  all  pa- 
tients were  made  sterile  from  this  operation  but  that 
there  was  a  percentage  who  were  made  sterile  by 
this  operation.  I  also  said  the  thing  to  do  was  to 
explain  to  the  patient  the  possibility  of  making  him 
sterile  and  that  he  should  be  told  that  before  the 
operation.  I  can  report  two  cases  in  which  this 
happened  and  I  did  not  do  the  original  operation 
in  both  of  them. 

216 


Dr.  Herbst:  Out  of  how  many  cases?  We 
know  that  many  cases  of  seminal  vesicle  infections 
are  sterilized  by  the  disease.  Also,  that  any  of 
the  operations,  such  as  vesiculectomy  or  vesiculot- 
omy, may  be  followed  by  sterility,  but  I  am  satis- 
fied that  if  this  does  occur  following  vasotomy,  it 
is  extremely  rare. 

Dr.  Kretschmer:  It  seems  to  me  that  this 
question  of  sterility  following  vasotomy,  vesiculot- 
omy, and  vesiculectomy  operations  will  make  a 
good  subject  for  a  meeting  sometime  next  winter. 
Many  of  us  know  a  case  or  a  couple  of  cases  that 
we  could  report  and  we  might  devote  an  evening 
to  the  subject. 

Dr.  E.  W.  White:  In  my  opinion  Dr. 
Bremerman  has  asked  the  most  difficult  question  of 
the  evening,  viz. :  "In  what  class  of  cases  is  semi- 
nal vesiculectomy  indicated  and  when  would  vesi- 
culotomy be  advised?"  It  is  almost  impossible  for 
me  to  advance  any  set  rule  on  this  important  ques- 
tion. We  are  all  aware  of  the  fact  that  a  pus 
vesicle  should  be  opened  and  drained,  also  those 
cases  of  acutely  distended  vesicle  which  are  pro- 
ductive of  urinary  retention ;  whereas  the  cases  that 
are  studded  with  abscesses,  also  the  chronic  cases 
of  long  standing  which  are  not  benefited  by  the 
usual  palliative  measures  we  advise  a  seminal  vesi- 
culectomy. I  have  in  mind  one  case  in  which  we 
did  a  vesiculotomy  and  prostatotomy  and  at  a  later 
date  a  vesiculectomy  with  gratifying  result. 

Relative  to  the  duration  of  the  time  necessary  to 
remain  in  the  hospital,  would  say  that  it  generally 
takes  two  to  three  weeks,  and  the  patients  gener- 
ally object  to  this.  However  we  are  in  the  habit 
of  advising  operative  interference  in  every  case 
that  is  necessary  regardless  of  time  limit,  etc. 

It  is  true  that  the  discharge  does  remain  after 
these  patients  have  been  operated  and  sometimes 
remains  constant  over  a  long  period.  I  think  Fuller 
makes  the  statement  that  you  should  not  treat  the 
discharge  that  persists  after  vesiculectomy.  We 
have  treated  these  cases  locally  but  the  discharge 
has  persisted  in  many  of  them. 

"How  many  cases  have  we  cured?"  I  cannot 
give  you  the  exact  figures  but  I  think  fully  90  per 
cent,  have  been  cured,  all  symptoms  being  relieved. 
The  urine  clears  up,  they  are  sexually  normal  and 
general  health  satisfactory.  I  cannot  tell  you  the 
exact  number  of  cures. 

Dr.  Eisenstaedt  spoke  of  the  subacute  or  catar- 
rhal type  of  cases  and  I  have  mentioned  this  type 
in  my  classification.  We  have  noted  that  many 
of  these  cases  complain  of  persistent  pain  at  the 
urinary  meatus  following  vesiculectomy  and  have 
used  caput  applications  as  a  therapeutic  measure, 
with  good  results. 
*  *  *  *  ^i;  *  ;»•. 

The  second  item  on  the  program  was  a  discus- 
sion of  aspermia,  with  report  of  a  case,  by  Dr.  V. 
D.   Lespinasse.      (July  issue  this  journal.) 

217 


In  opening  the  discussion.  Dr.  Bremerman  said: 
This  question  of  aspermia  I  think  is  an  exceed- 
ingly interesting  one  and  one  which  most  of  us 
have  had  some  experience  in  handhng.  I  don't 
think  that  I  have  ever  seen  the  exact  type  that  Dr. 
Lespinasse  has  described,  but  I  have  seen  many 
cases  in  married  men  who  have  come  in  for  exam- 
ination for  the  purpose  of  knowing  why  they  could 
not  have  families,  and  in  the  examination  of  a 
condum  specimen  I  have  found  no  sperm  at  all.  I 
would  like  to  ask  Dr.  Lespinasse  what  he  has  done 
for  this  type  of  case. 

Dr.  D.  Lieberthal:  Inasmuch  as  in  the 
condition  described  sperma  was  generated,  but  not 
ejaculated,  we  should  rather  use  for  it  the  term 
blocking  of  ejaculation  instead  of  aspermia.  The 
whole  subject  of  disturbances  in  the  male  sexual 
functions  is  very  interesting,  and  I  may  be  permitted 
to  touch  also  on  the  question  of  azoospermia.  In 
some  individuals  who  are  otherwise  well,  there 
is  a  continuous  absence  of  spermatozoa.  The  con- 
dition is  congenital.  There  is  another  large  class 
where  it  is  temporary  or  may  become  permement. 
So  we  find  it  after  great  loss  of  semen  from  sexual 
excess,  after  often  repeated  nightly  emissions. 
Azoospermia  may  also  occur  in  tuberculosis,  alco- 
holism and  various  chronic  diseases,  and  in  nervous 
affections.  We  are  frequently  called  upon  to  ex- 
amine sperma  for  spermatozoa.  Even  in  using  all 
precautions,  one  is  not  justified  to  draw  conclusions 
from  just  one  examination.  Only  after  such  have 
been  made  repeatedly  and  at  long  intervals,  can 
an  opinion  be  expressed.  This  is  especially  true 
when  testimony  is  to  be  given  in  court.  I  recall 
one  case  which  is  quite  instructive.  The  patient  was 
healthy  in  every  respect  and  was  fulfilling  his  mari- 
tal duties  well,  but  no  impregnation  took  place.  His 
wife  was  anxious  to  have  children.  She  was  ex- 
amined and  found  to  be  in  excellent  condition  by 
a  gynecologist.  I  examined  his  semen  a  few  limes 
within  a  month.  No  spermatozoa  were  found. 
After  a  long  interval  such  were  discovered  in  the 
semen,  but  they  were  dead.  The  examinations 
were  continued  and  gradually  live  spermatozoa  were 
found  in  increasing  number. 

The  case  reported  by  Dr.  Lespinasse  is  exceed- 
ingly interesting  and  I  enjoyed  listening  to  it  very 
much. 

Dr.  V.  D.  Lespinasse:  I  would  like  to  get 
clear  in  your  minds  the  difference  between  aspermia 
and  azoospermia.  In  aspermia  if  you  examine  the 
condum  there  will  be  nothing  in  it.  I  brought  this 
condum  to  show  a  marked  diminution  in  the  amount 
of  semen  from  a  man  who  probably  has  a  lesion 
in  both  of  his  ejaculatory  ducts  and  all  you  obtain 
in  his  condum  is  prostate  and  urethral  gland  secre- 
tion. There  is  probably  no  more  than  half  a  c.c. 
Ordinarily  there  is  about  four  c.c,  with  a  maximum 
normal  of  about  nine  or  ten  c.c.  In  looking  up 
the  literature  a  little  bit  I   found  that  these  cases 

218 


were  confused  with  cases  of  malemission.  One 
interesting  malemission  case  was  where  the  semen 
was  discharged  up  in  the  epigastric  region  through 
three  openings.  I  saw  a  guinea  pig  a  year  ago  with 
tuberculosis  and  the  bladder  was  filled  with  sper- 
matozoa from  a  fistula  up  between  the  bladder  and 
the  seminal  vesicle.  That  was  a  case  of  malemis- 
sion. The  treatment  in  these  cases  of  idiopathic 
aspermia  has  been  along  antispasmodic  lines.  This 
particular  case  that  I  have  told  you  about  has  just 
come  under  observation  and  has  not  yet  been 
treated. 

The  observation  of  Dr.  Lieberthal  interested  me 
very  greatly.  I  have  had  the  experience  of  exam- 
ining semen  for  sperm  and  usually  I  find  it  present 
when  someone  else  has  said  it  was  absent.  We 
know  that  we  can  have,  depending  upon  the  gen- 
eral health  of  the  individual,  a  marked  difference 
in  the  number  and  particularly  the  motility  and 
viability  of  the  spermatozoa. 


219 


CONTRIBUTORS  TO  THIS  VOLUME. 


PAGE 

Abt,  Isaac  A 1  34 

Bacon,  Charles  S 176 

Belfield,  William  T 123 

Blount,  A.  L 150 

Bremerman,  Lewis  W 138 

Brennemann,  Joseph 171 

Cary,  French  S 1  02 

Charlton,  Frederick 31 

Corbus,  B.  C 95 

Curtis,  Arthur  H 1  62 

Ehrich,  William  S 35 

Eisendrath,  Daniel  N 1  88 

Eisenstaedt,   J.    S 18 

Elam,  W.  T 92 

Gardner,  James  A 91 

Gradwohl,  R.  B.  H 115 

Grulee,  Chfford  G 158 

Harpster,   Charles    M 90 

Heaney,  N.  Sproat 1  70 

Herbst,    Robert   H 1  30 

Herrick,  F.  C 91 

Jost,  William  E 115 

Kohscher,  Gustav 26 

Koll.   Irvin  S 141 

Kraus.  Harry  A 195 

Kretschmer,  Herman  L 1 

Lespmasse,   Victor   D 1  28 

Lieberthal,  D 218 

Lower,  W.   E 101 

McCollom.  Wm.   E 91 

McKenna,    Charles    M 192 

Marchildon,  J.  W 121 

Mark,  Ernest  G 37 

Martin,  W.   F 97 

Mowry,  Albert  E 1  44 

Plaggemeyer,  H.  W 79 

Ravogli,  A 62 

221 


PAGE 

Ricketts.  B.  M 99 

Ries,   Emil    1  78 

Robbins,  Frederick  W 56 

Scherck,  Henry  J 28 

Schmidt,   Louis   E 123 

Smith,  E.  O 40 

Smith,  Theo.  H 92 

Staley,  R.  W 73 

Stokes.  A.  C 49 

Thomas,  Gilbert  J 66 

Warden.  Carl  C 125 

Webster,  Clarence  J 181 

Webster,   Ralph   W 143 

Welfeld,    Joseph 215 

White,    Edward   W 205 

Wright.   Franklin   B 90 


222 


UBk, 

713224 

UNIVERSITY  OF  CALIFORNIA  LIBRARY 


: 


